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Elevated mean pulmonary artery pressure in patients with mild-to-moderate mitral stenosis: a useful predictor of worsening renal functions?/ Hafif ve orta derecede mitral darligi bulunan hastalarda artmis ortalama pulmoner arter basinci bozulan bobrek fonksiyonlarini gostermede yararli bir belirtec olabilir mi?


The incidence of acute rheumatic fever, and consequently of rheumatic valvular heart diseases, in developed countries has declined over the past decade. Although the occurrence of rheumatic heart diseases, including rheumatic mitral stenosis (MS), has declined in developed countries, it has remained a significant public health problem in developing ones (1). Symptoms of MS usually occur after a latent period following an initial acute rheumatic fever episode. This period might take more than 15 years. During this asymptomatic period, mitral valve area (MVA) reduces gradually. Clinical symptoms suggestive of MS occur when MVA of less than 2 [cm.sup.2], and the appearance of the diastolic pressure gradient between the left atrium and left ventricle, have resulted in a transmitral peak velocity of greater than 1 m/sec. Rates of 5-, 10- and 15-year survival with sole medical therapy (without surgery) were 44%, 32%, and 19%, respectively (2).

It is well known that renal dysfunction frequently accompanies the course of cardiac disorders and is strongly associated with morbidity and mortality (3-6). Worsening renal function (WRF) most commonly occurs in heart failure (HF) as a result of a complex interaction between the heart and kidneys. Recently published studies in HF have clarified its pathophysiology and underlined the importance of venous congestion, which can also be observed in MS due to increased right heart afterload (7-9). The relation between venous congestion and renal dysfunction has been shown in experimental studies (10, 11). These studies suggest that iatrogenically induced hypervolemia, and increase in renal vein pressure, lead directly to renal insufficiency independent of cardiac output or renal blood flow. This has also been shown to be a reversible phenomenon because lowering of renal vein pressure immediately improves urine output and glomerular filtration rate (GFR) (10, 11). Experimental studies have also indicated that temporary renal vein compression results in reduced sodium excretion, reduced GFR, and reduced renal blood flow (12-14). Increased venous congestion also causes an increase in renal interstitial pressure, which might lead to a hypoxic state of the renal parenchyma (15-18). Prolonged increases in plasma volume also attenuate several vascular reflexes, leading to an impaired arterial responsiveness, thereby further impairing the effective renal blood flow (19-22).

However, the prognostic significance of WRF and its clinical and echocardiographic determinants in MS are still unknown. In this study, we aimed to evaluate the clinical and echocardiographic parameters which might predict WRF in mild-to-moderate MS.


Study design

This study has a prospective cohort design.

Study population

Eighty consecutive patients with mild-to-moderate rheumatic MS, who were enrolled as part of another study, were prospectively considered in three participating centers between January 2006-January 2011 (23). Twenty patients (with similar age and gender distribution) from the original cohort declined to participate during the follow-up period. Patients with another severe accompanying valvular disorder, history of coronary artery disease, depressed ejection fraction, history of cardiac surgery, previous diagnosis of pulmonary disease, or previous diagnosis of chronic renal failure, were excluded from the study. Patients with a mitral valve area of < 1 [cm.sup.2] were also excluded, because these patients required surgical treatment at the time of evaluation. Patients with severe MS who declined surgery were also excluded because these patients already had low cardiac output (authors of this manuscript were considered that this might influence renal functions earlier than expected and could obscure other parameters' significance in determining worsening renal function). Therefore, 60 consecutive patients were enrolled. Patients were evaluated at every 6 months, unless any clinical deterioration and increase in symptoms were observed. The GFR of each participant was followed up at each visit.

The study protocol had been approved by the institutional ethics committee, and written informed consents were taken from all participants of this prospective observational cohort.

GFR assessment

The GFR was calculated according to the Modification of Diet in Renal Disease (MDRD) formula (86.3 x [sCr.sup.-1.154] x [age.sup.-0.203], female: MDRDx0.742, black or non-white: MDRDx1.212). Worsening of renal function was defined as a decline in GFR of [greater than or equal to] 20% on follow-up.

Clinical examinations

Clinical parameters including age, gender, height, weight, body surface area, body mass index, and presence and durations of comorbid disorders such as hypertension, diabetes mellitus, hyperlipidemia, smoking, characteristics of cardiac rhythm, and applied treatment as antiplatelets, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARB), diuretics, calcium channel blockers, digitalis, and warfarin were carefully evaluated and recorded.


Echocardiographic examinations were performed with a cardiac ultrasound system (Vivid 7, GE Healthcare, Wauwatosa, WI, US) to evaluate chamber quantification with a defined protocol (11, 24) by a physician who was unaware of patients' renal function. Resting heart rate was 55-85 bpm in all patients during echocardiographic examination. All echocardiograms were recorded and coded by echocardiographers without identities to eliminate interobserver variability. Recorded and coded data were put into random order by computer assistance and evaluated off-line by an expert echocardiographer. MVA was calculated by the two-dimensional planimetry method, and if the image quality was not sufficient, the Doppler pressure half time method was used (25). Transmitral gradients were calculated by the modified Bernoulli equation (26). Accompanying valvular regurgitations were quantified according to recent guidelines and categorized as mild-moderate (27). The modified Bernoulli equation derived from the tricuspid regurgitation jet velocity and estimated right atrial pressure from inferior vena cava collapsibility was used in determining systolic pulmonary artery pressure (sPAP) (28). Mean pulmonary artery pressure (mPAP) was calculated by the Masuyama method (29). Tricuspid annulus velocities (via tissue Doppler), right ventricular outflow time-velocity integral, Tei index, ejection times, intervals, and tricuspid annular plane systolic excursion were measured accordingly in all patients (30-33). Echocardiographic parameters at the time of initial evaluation were used in statistical analysis, as predictors of WRF during follow-up.

Statistical analysis

All statistical procedures were performed using SPSS software version 15.0 (SPSS Inc., Chicago, IL). Continuous variables were expressed as mean [+ or -] standard deviation or median (interquatile range) in the presence of abnormal distribution, categorical variables as percentages. Comparisons between groups of patients were made by use of a Chi-square test for categorical variables, an independent samples t-test for normally distributed continuous variables, and the Mann-Whitney U test when the distribution was skewed. Univariate Cox proportional hazards analysis was used to quantify the association of variables with worsening renal function. Variables found to be significant at the p <0.1 level in univariate analysis were used in a multivariate Cox proportional hazards model with a forward stepwise method in order to determine the independent predictors of WRF. Receiver operator characteristic (ROC) curve analysis was performed to identify the optimal cut-off point of mPAP (at which sensitivity and specificity would be maximal) for the prediction of WRF. Areas under the curve (AUC) were calculated as measures of the accuracy of the tests. We compared the AUC by use of the Z test. Kaplan-Meier curves were used to show the development of WRF in two patient subgroups, defined as having no increased ([less than or equal to] 21 mmHg) or increased (>21 mmHg) mPAP based on a cut off value. A p-value of 0.05 was considered as statistically significant.


Baseline clinical characteristics and echocardiographic parameters

Sixty mild-to-moderate MS patients were followed up for a mean period of 34 [+ or -] 13 months (range 1-60). The mean age of the study population was 50 [+ or -] 13 years (85% females, 15% males). The mean MVA and mean transmitral gradient of the study population were 1.6 [+ or -] 0.2 [cm.sup.2] and 6.4 [+ or -] 2.9 mmHg, respectively. Comparison of patients' baseline clinical characteristics and echocardiographic parameters, according to the presence of WRF, has been shown in Table 1 and Table 2. Worsening renal function on follow-up was more frequent in patients of male gender, or with a history of digitalis use (p=0.025 and p=0.044, respectively. Maximum tricuspid regurgitation velocity (TR max velocity), sPAP and mPAP were higher in patients with worsening renal function (p <0.05). Other baseline clinical and echocardiographic parameters were similar between groups (Table 1 and 2).

Regression analyses for the development of worsening renal function

Results of the univariate and multivariate Cox proportional hazards analyses have been shown in Table 3. Male gender, mPAP, TR max velocity, sPAP, digitalis and antiplatelet agent usage, right atrial diameter, and Tei index were found to be univariate predictors of WRF. In the multivariate Cox proportional hazards model, mPAP (HR=1.136, 95% CI: 1.058-1.220, p<0.001) and male gender (HR=4.110, 95% CI: 1.812-9.322, p=0.001) were associated with an increased risk of WRF during follow-up.

ROC curve for mPAP to predict worsening renal function

According to the ROC curve analysis, the optimal cut-off value of mPAP to predict WRF was measured as more than 21 mmHg, with 78.6% sensitivity and 58.7% specificity (AUC 0.725, 95% CI 0.595-0.838, Fig. 1). On the other hand, mPAP of >36.21 mmHg was found to have 100% specificity for WRF on follow-up, though sensitivity was low (14.3%).

Survival analysis

According to the Kaplan-Meier curve, a significant difference was found between those who had mPAP of >21 mmHg, and those who did not, in terms of worsening renal function (p=0.006), and the difference between the groups became bigger after 30 months of follow-up (Fig. 2).


In this study, we aimed to evaluate whether clinical and echocardiographic parameters might predict WRF in patients with mild-to-moderate mitral stenosis. Male gender, mPAP, TRmax velocity, sPAP, digitalis and antiplatelet agent usage, right atrial diameter and TEI index were found to be univariate predictors of worsening renal function. However, even after controlling these parameters, we demonstrated that only mPAP and male gender were independently associated with an increased risk of WRF during follow-up in patients with mild-to-moderate mitral stenosis.

The kidney and the heart are two closely interrelated organs. It is well known that any disorder affecting one of the two deteriorates the other's functional status. Deterioration of this close interrelation between these two organ systems is known as "cardio-renal syndrome," and studies in HF have clarified the pathophysiological mechanisms behind this syndrome. It has been thought that renal dysfunction in HF is attributable to low cardiac output, which consequently causes reduction in blood flow and renal perfusion pressure (9, 34). Decreased cardiac output also activates the renin-angiotensin-aldosterone system and the sympathetic nervous system, which in turn causes congestion and constriction in afferent arterioles. These results in further decreases in renal perfusion pressure (34). Theoretically, the above-mentioned pathophysiological mechanism is valid; however, recent studies suggest different mechanisms. Heywood et al., (35) have shown that renal dysfunction is similar in patients with systolic and diastolic dysfunction; this result suggests mechanisms other than low cardiac output. Recently published HF studies have explained the role of venous congestion in renal dysfunction (7-9, 36, 37). Some other studies have suggested right atrial and central venous pressure, rather than cardiac index, as the main predictors of worsening renal function (37, 38). Increased oxidative stress and inflammation in the tubule-interstitium developed after venous congestion may also have a role in renal dysfunction (39).

Renal dysfunction may also potentially complicate the course of rheumatic MS. Just like in HF, right ventricular dysfunction secondary to increased right heart afterload, and venous congestion, are also common findings of MS. However, the potential role of echocardiography in predicting WRF in MS is unknown. In this study, we investigated clinical and echocardiographic indices of WRF in MS. In our study, mPAP was found to be an independent predictor of WRF. Systolic PAP and TR max velocity were other predictors in univariate analysis, though they lost their significance after multivariate analysis. On the other hand, in this study, echocardiographic indices of MS severity including transmitral gradients and valve area, as well as left atrial diameters, had no influence in predicting WRF These findings were consistent with the above-mentioned data derived from HF studies, which proved the role of venous congestion and right ventricular dysfunction in WRF It is notable that cardiac output may have a potential role in worsening renal function; however, we excluded patients with severe MS since these patients needed intervention at the time of evaluation. In our study, right ventricular diameter was within normal range and did not differ between groups. This was also true for TAPSE and Tei indices. These findings suggest that right ventricular systolic function was relatively preserved at the time of evaluation; however, an afterload mismatch of the right ventri cle, in the form of increased pulmonary pressure, was already there. This increased afterload seemed to bring about right ventricular diastolic dysfunction, which in turn increased right atrial pressures and caused venous congestion. Increased transverse right atrial diameter, observed in this study, supports this hypothesis (Table 2). The right atrial area was also increased in patients with WRF, though it could not reach statistical significance (p=0.101). We think invasive measurement of right atrial pressure might clarify this hypothesis.

Study limitations

Although a lack of invasive measurements was the major limitation of our study, we did not consider invasive assessment, since it might cause ethical problems if performed in cases of mild-to-moderate MS. Central venous pressure and inferior vena cava diameters, which remain other important study limitations, were also not recorded in our study. Because right ventricular systolic function was preserved, this issue was overlooked. Male gender was also found to be a predictor of WRF; however, it is better not to generalize about this, since there were relatively few male patients in the cohort, which is another limitation of this study. The number of patients enrolled in this study was another limitation; therefore, our findings should not be generalized. These findings should be supported by further studies conducted with a sufficient number of patients.


Increased mPAP at the time of evaluation, in patients with mild-to-moderate MS, seems to predict WRF during follow-up; hence, we think close monitoring of these patients, particularly those with mPAP of > 36.2 mmHg-which as a rule designates very high specificity in test results-may be useful in terms of renal function.

doi: 10.5152/akd.2013.144

Conflict of interest: None declared.

Peer-review: Externally peer-reviewed.

Authorship contributions: Concept--M.B.Y., C.Z., A.Z.; Design--M.B.Y., G.A., G.B.; Supervision--M.B.Y., I.T., O.O.T.; Resource--I.T., M.B.Y.; Material--G.A.; Data collection&/or Processing--G.A., G.B.; Analysis &/or interpretation--A. Z.; Literature search--C.Z., I.E.; Writing--C.Z., A.Z.; Critical review--O.O.T., M.B.Y., A.Z.; Other--I.E.


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Cafer Zorkun, Gullu Amioglu [1], Gokhan Bektasoglu [1], Ali Zorlu [1], Ismail Ekinozu [2], Okan Onur Turgut [1], Izzet Tandogan [1], Mehmet Birhan Yilmaz [1]

Department of Cardiology, Yedikule Thoracic Diseases&Surgery Education and Research Hospital, Istanbul-Turkey

[1] Department of Cardiology, Faculty of Medicine, Cumhuriyet University, Sivas-Turkey

[2] Department of Cardiology, Faculty of Medicine, Duzce University, Duzce-Turkey

Table 1. Baseline characteristics and differences between patients
who did and did not develop worsening renal function during

Variables              Patients without    Patients with       * p
                       worsening renal    worsening renal
                         function on        function on
                       follow up (n=46)   follow up (n=14)

Mean age, years         49 [+ or -] 12     52 [+ or -] 16     0.486
Male gender, n (%)          4 (9)              5 (36)         0.025
Height, cm              158 [+ or -] 5    161 [+ or -] 10     0.387
Weight, kg              73 [+ or -] 14     70 [+ or -] 15     0.471
BSA, [m.sup.2]         1.8 [+ or -] 0.1   1.7 [+ or -] 0.2    0.598
BMI, kg/[m.sup.2]       29 [+ or -] 6      27 [+ or -] 6      0.245
Follow-up time,         34 [+ or -] 14     36 [+ or -] 10     0.592
Presence of                 18(39)             8(57)          0.235
Baseline GFR,          107 [+ or -] 34    100 [+ or -] 50     0.570
Final GFR,             112 [+ or -] 35     57 [+ or -] 33    < 0.001
Change of GFR, %,        0 (-12.5/25)      -40 (-57/-31)     < 0.001
Presence of                 6 (13)             1 (7)          1.000
  diabetes mellitus
Duration of              3 [+ or -] 6      4 [+ or -] 10      0.804
  mellitus, years
Hyperlipidemia,            11 (24)             3 (21)         1.000
  n (%)
Duration of             1.5 [+ or -] 2      1 [+ or -] 1      0.678
Smoking, n (%)              5 (11)             2(14)          0.660
Duration of             5 [+ or -] 10      12 [+ or -] 20     0.759
  smoking, years
Atrial                     18 (39)             5 (36)         0.817
  n (%)
Antiplatelet               34 (74)             7 (50)         0.111
  agents, n (%)
Beta blockers,             27 (59)             8 (57)         0.918
  n (%)
ACE inhibitors/            16 (35)             5 (36)         1.000
  ARB, n (%)
Diuretics, n (%)            11(24)             2 (14)         0.713
Calcium canal              13 (28)             3 (21)         0.740
  blockers, n (%)
Digitalis, n (%)            5 (11)             5 (36)         0.044
Warfarin, n (%)            21 (46)             5 (36)         0.508

Data are presented as number (percentage) and mean [+ or -] SD or
median (interquartile range) values 'Independent samples t-test,
Mann-Whitney U test, and Chi-square test

ACEI--angiotensin--converting enzyme inhibitor, ARB--angiotensin
receptor blocker, BMI--body mass index, BSA--body surface area

Table 2. Comparison of the echocardiographic parameters between
patients who did and did not develop worsening renal function during

Variables               Patients without      Patients with       * p
                        worsening renal      worsening renal
                          function on          function on
                        follow up (n=46)     follow up (n=14)

E velocity, m/sec       1.3 [+ or -] 0.7     1.4 [+ or -] 0.5    0.882
A velocity, m/sec       1.5 [+ or -] 0.5     1.4 [+ or -] 0.3    0.593
E/A ratio               0.8 [+ or -] 0.4     0.9 [+ or -] 0.3    0.648
Ejection                 55 [+ or -] 7        56 [+ or -] 8      0.647
  fraction, %
LV diastolic             92 [+ or -] 24       96 [+ or -] 39     0.685
  volume, mL
LV systolic              41 [+ or -] 14       39 [+ or -] 14     0.602
  volume, mL
Left atrial             4.7 [+ or -] 0.8     4.6 [+ or -] 0.8    0.667
  diameter 4C1, cm
Left atrial             6.8 [+ or -] 1.0     6.7 [+ or -] 0.9    0.915
  diameter 4C2, cm
Area of left atrium,     34 [+ or -] 47       28 [+ or -] 9      0.610
Right atrial            3.7 [+ or -] 0.9     4.3 [+ or -] 0.8    0.058
  diameter 4C1, cm
Right atrial            5.3 [+ or -] 0.9     5.5 [+ or -] 1.0    0.364
  diameter 4C2, cm
Area of right            19 [+ or -] 7        23 [+ or -] 8      0.101
  atrium, [cm.sup.2]
RV diameter D2, cm      3.1 [+ or -] 0.6     3.4 [+ or -] 0.5    0.266
E' velocity, m/sec     0.15 [+ or -] 0.04   0.16 [+ or -] 0.04   0.566
A' velocity, m/sec     0.20 [+ or -] 0.2    0.16 [+ or -] 0.06   0.565
S velocity, m/sec      0.15 [+ or -] 0.15   0.13 [+ or -] 0.04   0.664
RV Ejection time,       287 [+ or -] 41      291 [+ or -] 47     0.798
IVCT, msec               74 [+ or -] 20       71 [+ or -] 11     0.624
IVRT, msec               77 [+ or -] 19       73 [+ or -] 19     0.479
TEI index              0.52 [+ or -] 0.13   0.46 [+ or -] 0.17   0.189
RV fractional area       16 [+ or -] 4        18 [+ or -] 4      0.174
  change, %
TR max velocity,        2.7 [+ or -] 0.3     3.1 [+ or -] 0.5    0.007
RVOT TVI, cm             18 [+ or -] 5        17 [+ or -] 4      0.590
PVmax, m/sec            0.8 [+ or -] 0.1     0.8 [+ or -] 0.1    0.591
PAcT, msec              112 [+ or -] 25       97 [+ or -] 25     0.051
TAPSE, cm               2.2 [+ or -] 0.6     2.1 [+ or -] 0.5    0.541
Aortic                       28/18                 7/7           0.680
Mitral                       25/21                 8/6           1.000
Area of mitral          4.8 [+ or -] 2.8     4.9 [+ or -] 3.8    0.881
Tricuspid                    33/13                 8/6           0.338
Area of tricuspid       4.2 [+ or -] 3.6     4.3 [+ or -] 2.2    0.919
MVA planimetric,        1.6 [+ or -] 0.2     1.5 [+ or -] 0.2    0.525
MVA PHT, [cm.sup.2]     1.6 [+ or -] 0.3     1.5 [+ or -] 0.3    0.522
Maximum MV gradient,   13.7 [+ or -] 5.1    15.0 [+ or -] 6.0    0.434
Mean MV gradient,       6.2 [+ or -] 2.8     6.9 [+ or -] 3.6    0.460
Systolic PA            30.6 [+ or -] 7.9     39 [+ or -] 13.9    0.048
  pressure, mmHg
Mean PA pressure,      20.7 [+ or -] 5.3    26.4 [+ or -] 8.1    0.003

Data are presented as number (percentage) and mean [+ or -] SD values.

* Independent samples t-test, Mann-Whitney U test, and Chi-square test

A--peak late diastolic mitral inflow velocity, A'--annular late
diastolic wave, E--peak early diastolic mitral inflow velocity,
E'--annular early diastolic wave, IVCT--isovolumic contraction time,
IVRT--isovolumic relaxation time, LV--left ventricle, 4C1--measurement
taken in a plane perpendicular to the long-axis of the atrium and
extends from the lateral border to the interatrial septum in apical
four chamber view at end-systole, MV--mitral valve, MVA--mitral valve
area, 4C2--measurement from the back wall to the line across the hinge
points of the mitral or tricuspid valve in apical four chamber view at
end-systole, PA--pulmonary artery, PacT--pulmonary acceleration time,
PHT--pressure half-time, Pvmax--pulmonary maximal velocity, RV--right
ventricle, RVOT TVI--right ventricular outflow time-velocity integral,
S--systolic annular myocardial velocity, TAPSE--tricuspid annular
plane systolic excursion, TR--tricuspid regurgitation

Table 3. Univariate and multivariate predictors of
worsening renal function

Variables                     HR        95% CI        p

Male gender                  2.697   1.446-5.028    0.002
Mean PA pressure, mmHg       1.084   1.025-1.147    0.005
TR max velocity, m/sec       3.580   1.457-8.798    0.005
Systolic PA pressure, mmHg   1.047   1.013-1.183    0.007
Digitalis usage              3.591   1.192-10.816   0.023
Right atrial diameter, cm    1.666   0.990-2.802    0.054
Antiplatelet agents          2.743   0.945-7.963    0.064
Tei index                    0.037   0.001-1.727    0.093

Variables                     HR       95% CI       * p

Male gender                  4.110   1.812-9.322   0.001
Mean PA pressure, mmHg       1.136   1.058-1.220   <0.001
TR max velocity, m/sec
Systolic PA pressure, mmHg
Digitalis usage
Right atrial diameter, cm
Antiplatelet agents
Tei index

* Multivariate cox proportional hazard analysis with forward
stepwise method

Dependent variable--worsening renal function, independent
variables: male gender, mean PA pressure, TR max
velocity, systolic PA pressure, digitalis usage, right
atrial diameter, antiplatelet agents, Tei index.

All the variables from Table 1 and 2 were examined and only
those significant at p < 0.1 level are shown.

Multivariate cox proportional hazard model including all
univariate predictors.

CI--confidence interval, HR--hazard ratio, PA--pulmonary artery,
TR--tricuspid regurgitation
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Title Annotation:Original Investigation/Ozgun Arastirma
Author:Zorkun, Cafer; Amioglu, Gullu; Bektasoglu, Gokhan; Zorlu, Ali; Ekinozu, Ismail; Turgut, Okan Onur; T
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Article Type:Report
Date:Aug 1, 2013
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