|Year : 2019 | Volume
| Issue : 4 | Page : 150-159
The assessment of left/right ventricular strain and deformation in patients with severe rheumatic mitral stenosis before and after balloon mitral valvuloplasty using speckle tracking echocardiography
Sudarshan Kumar Vijay, Bhuwan Chandra Tiwari, Pawan Mehta, Mukul Misra
Department of Cardiology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
|Date of Submission||08-Sep-2019|
|Date of Decision||08-Sep-2019|
|Date of Acceptance||08-Oct-2019|
|Date of Web Publication||11-Dec-2019|
Dr. Sudarshan Kumar Vijay
Department of Cardiology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Gomti Nagar, Lucknow - 226 010, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Rheumatic mitral stenosis (MS) poses substantial burden in developing countries and is an important cause of cardiovascular morbidity. Speckle tracking echocardiography is a novel technique which assesses the left and right ventricular mechanics and deformation by grey scale imaging. Aims and Objectives: We aimed to assess the left and right ventricular strain and deformation in patients with severe rheumatic mitral stenosis to analyse the subclinical ventricular dysfunction in these patients as compared to healthy controls and to see the effect of balloon mitral valvotomy (BMV) on these parameters. Material and Methods: 50 patients of severe rheumatic mitral stenosis were recruited into study and divided into two groups: cases ( severe MS patients underging BMV, n = 30 ) case controls(severe MS patients on medical management not opting for BMV, n = 20). 10 -healthy normal controls were taken. Baseline LV strain and deformation was assessed in these patients and effect of balloon mitral valvotomy was seen on these parameters in cases at early (24-48 hrs) and short term (1-month) period as compared to changes in case controls and normal controls. Results: Baseline LV global longitudinal (GL) (-13.1 ± 3.67) and circumferential strain (GC) (-19.18 ± 7.58) was significantly reduced in cases as compared to healthy controls (-22.17 ± 2.30) and (-30.21 ± 4.17) respectively (p < 0.001). Right ventricular global longitudinal strain was also significantly reduced in cases (-9.43 ± 5.75). LV and RV rotational parameters were also reduced. BMV significantly improved in left ventricular GL strain from baseline (-13.10 ± 3.67) to post 24-48 hrs (-14.77 ± 3.98) and post one month (-17.20 ± 3.44) and GC strain from baseline (-19.18 ± 7.58, p=<0.05). RV global longitudinal strain also changed significantly (p < 0.01) from baseline (-9.43 ± 5.75) to post 24-48 hrs (-13.87 ± 8.93) and post one month (-17.37 ± 5.72). Conclusions: LV and RV strain and deformation is reduced in severe mitral stenosis patients. 2D speckle tracking echocardiography can detect these early changes in LV and RV function before overt systolic dysfunction. BMV significantly improves LV/RV strain and deformation at early and short term period.
Keywords: Balloon mitral valvotomy, rheumatic mitral stenosis, speckle tracking echocardiography, ventricular strain
|How to cite this article:|
Vijay SK, Tiwari BC, Mehta P, Misra M. The assessment of left/right ventricular strain and deformation in patients with severe rheumatic mitral stenosis before and after balloon mitral valvuloplasty using speckle tracking echocardiography. Heart India 2019;7:150-9
|How to cite this URL:|
Vijay SK, Tiwari BC, Mehta P, Misra M. The assessment of left/right ventricular strain and deformation in patients with severe rheumatic mitral stenosis before and after balloon mitral valvuloplasty using speckle tracking echocardiography. Heart India [serial online] 2019 [cited 2020 Jan 21];7:150-9. Available from: http://www.heartindia.net/text.asp?2019/7/4/150/272664
| Introduction|| |
Rheumatic heart disease (RHD) is one of the most common forms of cardiac diseases worldwide, particularly in developing countries, where it remains the second most common cause of cardiovascular morbidity and mortality after atherosclerotic vascular disease. Even in developed nations, where RHD has been almost eradicated, recent reports have emphasized the disturbing possibility of a resurgence of this disease.,, Mitral stenosis (MS) is the most common valve lesion seen in chronic RHD and usually manifests with exertional dyspnea and features of right heart failure resulting from pulmonary hypertension. MS does not produce any significant hemodynamic load on the left ventricle, and therefore, left ventricle (LV) systolic dysfunction is pretty uncommon in the setting of MS.,, However, a few studies have reported that LV systolic dysfunction may not be so uncommon in patients with rheumatic MS.,,,,,,, The mechanisms proposed to explain this LV systolic dysfunction are chronically reduced preload resulting in adverse LV remodeling, and the extension of inflammatory process from MV apparatus into the adjacent myocardium.
Right ventricular (RV) function plays an important role in development of clinical symptoms and prognosis in patients with MS. This is primarily because of hemodynamic effect on RV due to pulmonary hypertension. RV dysfunction is not detected clinically until the development of clinical signs of systemic venous congestion. RV functional assessment is difficult and not done routinely because of its complex anatomy and high load dependence. Many indices have been developed for quantifying RV function among which, strain and strain rate are relatively new. Myocardial strain is a measure of tissue deformation, which is expressed as a percentage change, whereas, strain rate is the rate of such deformation.
Long-term improvement in RV function in patients with MS has been shown in different hemodynamic studies after percutaneous balloon mitral valvuloplasty (BMV)., However, immediate effect of BMV on RV function was examined in only few studies.,,
Two dimensional speckle-tracking echocardiography (STE) is being used now a days to assess ventricular systolic functions, as it permits more comprehensive evaluation of myocardial contractile function than conventional measures. We planned to assess the burden of ventricular (LV and RV) systolic dysfunction, its determinants, and its reversibility with percutaneous balloon mitral valvuloplasty using speckle tracking echocardiography in patients with severe MS.
| Materials and Methods|| |
This study was a prospective study performed in a tertiary care center, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow in patients with severe MS, over one year period. Patients were analysed pre and post intervention (Medical/BMV) using speckle tracking echocardiography and baseline LV and RV systolic functions were compared with healthy controls.
- Age->10 years
- Sex – both male and female
- Severe MS suitable for BMV
- Ready to give informed consent.
- patients having coexistent significant MR or aortic valve disease
- Established coronary artery disease or any other structural heart disease
- Diabetes mellitus, COPD, pregnancy, malignancy, CKD
- Patients who developed more than moderate MR after BMV
- Any contraindication to BMV.
Patients visiting cardiology OPD or IPD with the diagnosis of rheumatic MS were thoroughly examined after taking detailed history and were subjected to routine hematological and biochemical investigations. Transthoracic echocardiographic examination was done by Philips IE 33 (Philips Medical Systems, USA) machine and once BMV was planned on the basis of echo findings, speckle tracking echocardiography was done and recorded by single observer (PM). All examinations were recorded for offline analysis. Ventricular strain and strain rate were derived from apical four chamber, three chamber and short axis views.
Subjects were divided into three groups-
- Cases (n = 30): Patients with severe MS undergoing BMV
- Case controls (n = 20): Patients with severe MS who did not give consent for BMV and chose medical management
- Healthy controls (n = 10).
Cases who underwent BMV were analysed pre and post BMV and detailed echocardiographic and STE was done at baseline, 24-48 hrs after BMV and at post one month after BMV. During BMV different cardiac catheterization parameters were examined and recorded (a wave, v wave, LA mean pressure, EDG and LVEDP). Appropriate statistical analysis was applied and different parameters were compared pre and post BMV (24-48 hrs and post one month).
Case controls (patients with severe MS on medical management) were analysed at baseline and at one month follow up. Detailed 2D echocardiographic and STE was done and recorded. Appropriate statistical analysis was applied and different parameters were compared from baseline with one month. Detailed 2D echocardiographic and STE was done and recorded at baseline of healthy controls and compared them with cases and cases controls.
The results are presented in mean ± SD and percentages. The Chi-square test was used to compare the categorical variables at the baseline between cases and controls. The Unpaired t-test was used to compare discrete variables at the baseline between cases and controls. The Paired t-test was used to compare the change in discrete variables from baseline to post and one month. The McNemar's and Kendal's tests were used to compare the changes in the dichotomous and categorical variables from baseline to post and one month respectively. The P value <0.05 was considered significant. All the analysis was carried out by using SPSS 16.0 version (Chicago, Inc., USA).
| Results|| |
Most of the cases (56.7%) controls (65%) and healthy controls (40%) were between 21-30 years of age with no significant (p > 0.05) difference in the age between the groups. Various baseline echocardiographic measurements in severe MS cases are presented in [Table 1]. Change in various catheterization parameters after BMV [Table 2] along with change in echocardiographic parameters was noted after BMV at 24-48 hrs and at one month [Table 3].
|Table 1: Baseline other echocardiographic measurements between cases and case controls (severe mitral stenosis)|
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|Table 2: Changes in various cathterization parameters after balloon mitral valvuloplasty|
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A significant (p < 0.01) decrease in the left atrial (LA) size was observed from baseline (3713.00 ± 847.15 mm 2) to post 24-48 hrs (3232.83 ± 806.72 mm 2) and at post one month (2955.03 ± 550.55 mm 2). No significant (p > 0.05) change was observed in MR from baseline to post and one month. Tricuspid regurgitation (TR) and pulmonary artery pressure (PAP) improved from baseline to post 24-48 hrs (p = 0.02) and (p = 0.002) and post one month (p = 0.03) and (p = 0.001) respectively.
A significant (p = 0.0001) decrease was observed in PASP from baseline (96.43 ± 27.01) to post 24-48 hrs (72.76 ± 24.65) and post one month (72.76 ± 24.65) associated with increase in mitral valve area (MVA) from baseline (0.75 ± 0.10 cm 2) to post 24-48 hrs (1.37 ± 0.12 cm 2) (p = 0.0001) and post one month (1.42 ± 0.1 cm 2 1) and significant (p = 0.0001) decrease was observed in mitral valve peak gradient from baseline (35.00 ± 10.91 mmHg) to post 24-48 hrs (16.63 ± 7.22 mmHg) and post one month (12.70 ± 4.75 mmHg) along with corresponding decrease in mitral valve mean gradient from baseline (17.73 ± 4.23 mmHg) to post 24-48 hrs (7.30 ± 5.55 mmHg) and post one month (5.87 ± 4.44 mmHg).
Baseline LV global longitudinal (GL) (-13.1 ± 3.67) [Figure 1] and circumferential strain (GC) (-19.18 ± 7.58) [Figure 2] was significantly reduced in cases as compared to healthy controls (-22.17 ± 2.30) and (-30.21 ± 4.17) respectively (p < 0.001). Right ventricular global longitudinal strain was also significantly reduced in cases (-9.43 ± 5.75) [Figure 3] as compared to controls (-21.23 ± 6.16). Baseline longitudinal strain values of individual LV and RV segments and ciurcumferential strain values of individual LV segments were also significantly reduced. Regional [Table 4] and global rotation [Table 5] of individual LV segments was also significantly reduced in severe MS cases as compared to healthy controls.
|Figure 1: Left ventricular global longitudinal strain among various groups at baseline|
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|Figure 2: Left ventricular global circumferential strain among various groups at baseline|
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|Figure 3: Right ventricular global longitudinal strain among various groups at baseline|
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A significant (p < 0.05) change was observed in left ventricular GL strain [Figure 4] from baseline (-13.10 ± 3.67) to post 24-48 hrs (-14.77 ± 3.98) and post one month (-17.20 ± 3.44) and GC strain [Figure 5] from baseline (-19.18 ± 7.58) to post 24-48 hrs (-24.86 ± 8.23) and post one month (-28.18 ± 7.10) (p < 0.01). RV global longitudinal strain [Figure 6] also changed significantly (p < 0.01) from baseline (-9.43 ± 5.75) to post 24-48 hrs (-13.87 ± 8.93) and post one month (-17.37 ± 5.72).
|Figure 4: Changes in left ventricular global longitudinal strain after balloon mitral valvuloplasty|
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|Figure 5: Changes in left ventricular global circumferential strain after balloon mitral valvuloplasty|
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|Figure 6: Changes in right ventricular global longitudinal strain after balloon mitral valvuloplasty|
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There is significant improvement in longitudinal strain in different LV segment [Table 6] as assessed by STE at post 24 – 48 hrs and post one month after BMV (p = 0.001) along with improvement in circumferential strain in different LV segments [Table 7] as assessed by STE at Post-24-48 hrs and post one month (p < 0.001). There was improvement in LV longitudinal strain rate in different LV segments (more in BAL, APL, MIS, APS) as assessed by STE at Post 24-48 hrs and Post one month after BMV along with in circumferential strain rate in different LV segments (more in BAS, BA, BIL, BIS) as assessed by STE at Post-24-48 hrs and post one month.
|Table 6: Changes in left ventricle longitudinal strain in individual left ventricle segments after balloon mitral valvuloplasty|
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|Table 7: Changes in left ventricle circumferential strain in individual left ventricle segments after balloon mitral valvuloplasty|
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A significant improvement in different RV segments in longitudinal strain [Table 8] as assessed by STE at Post-24-48 hrs and post one month after BMV (p = 0.0001) accompanied by improvement in different RV segments in longitudinal strain rate as assessed by STE at Post-24-48 hrs and post one month after BMV.
|Table 8: Changes in right ventricular logitudinal strain in individual right ventricular segments after balloon mitral valvuloplasty|
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There was significant improvement in regional rotation in different LV segments and RV segments at Post 24-48 hrs by STE and post one month [Table 9]. There was also significant improvement in global rotation in different LV segments as assessed by STE at Post-24-48 hrs and post one month after BMV (p = 0.0001) [Table 10].
|Table 9: Changes in left ventricle and right ventricular regional rotation after balloon mitral valvuloplasty|
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|Table 10: Changes in left ventricle global rotation after balloon mitral valvuloplasty|
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There was no significant improvement in LV GLS and GCS after one month [Figure 7] as assessed by STE among case controls and also no significant improvement in RV GLS after one month was noted among case controls (severe MS) [Figure 8]. No significant improvement was seen in regional rotation in different LV segments after one month among case controls.
|Figure 7: Changes in left ventricular global longitudinal/global circumferential strain in case controls|
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|Figure 8: Changes in right ventricular global longitudinal strain in case controls|
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There was no significant change in global rotation in different LV segments and regional rotation in different RV segments after one month among case controls.
| Discussion|| |
In the past, few studies have reported that LV and RV systolic dysfunction may not be uncommon and may indeed contribute to the development of symptoms in patients with MS.
Many haemodynamic and myocardial factors have been proposed to contribute to LV dysfunction in MS. These include reduction in LV filling, chronic myocardial inflammation, scarring of subvalvular apparatus, reduction of LV compliance, abnormal right–left septal interaction, and pulmonary hypertension.,, RV dysfunction is usually overlooked before the emergence of clinical signs of systemic venous congestion because of difficulties in the quantitative assessment of RV function. The researches for the most appropriate method to measure contractile characteristics of myocardium are still carrying on. Nowadays, a novel method, 2D strain, has been developed for the quantitative assessment of global and regional myocardial function.
In past couple of years, two studies have been published; one studying RV strain before and after BMV by Kumar et al. (2014) from India and another accessing LV strain before and after BMV by Sengupta et al. (2014) from the US. To the best of our knowledge, the present study is the only prospective study to assess serial changes in LV and RV myocardial deformation and different parameters before and after BMV in patients with isolated severe MS and compared them with patients with severe MS on medical follow up.
The major findings of present study are that (1) impairment of LV deformation is common in patients with isolated severe MS, as evidenced by reduced magnitudes.
Of LV longitudinal and circumferential strain despite almost preserved LVEFs in the majority of the patients; (2) these abnormalities of LV strain rapidly improve after BMV; and (3) LA size, transmitral pressure gradient appear to be the primary determinants of LV systolic dysfunction in these patients.
Left ventricle systolic function in patients with mitral stenosis
The status of LV systolic function in patients with MS has been a subject of investigation for several decades. The primary hemodynamic abnormality in MS is the obstruction to LV inflow, which results in elevation of LA pressure, leading in turn to pulmonary venous and arterial hypertension. Accordingly, exertional dyspnea, right heart failure, and atrial fibrillation, with its attendant complications, are the usual clinical manifestations of MS. Because there is no significant increase in LV afterload or preload in MS, the left ventricle is usually spared, and therefore LV systolic dysfunction is believed to be an exceedingly uncommon occurrence in patients with MS. However, several reports have suggested that abnormalities of LV mechanical performance may be common in MS and seen in as many as one quarter of all patients with isolated MS.
An important reason for the under recognition of LV contractile abnormalities in patients with MS, and the controversy related to this, has been our inability to accurately measure LV mechanical performance in these patients. Being a measure of global LV systolic function, LVEF decreases only when a significant amount of myocardial damage has already occurred. Studies using myocardial tissue velocity imaging and, more recently, strain imaging have demonstrated that in many cardiac illnesses, abnormalities of LV contraction become apparent long before they manifest as a decrease in LVEF., Being less angle dependent than Doppler-based methods, STE permits a more comprehensive assessment of LV myocardial contractile function than tissue Doppler velocity or strain imaging.,
We performed study on 50 patients with severe MS, and 10 healthy controls; GLS, GCS and global longitudinal strain rate were found to be significantly lower in patients with MS as compared with controls.
Right ventricular systolic function in patients with mitral stenosis
Our study showed that the RV systolic function is impaired in patients with severe MS as assessed by global and segmental RV strain. It correlates with earlier hemodynamic and clinical studies, which showed impaired RV function in MS patients. The cause of RV dysfunction is attributed to the increased RV afterload in these patients. Left atrial hypertension in these patients leads to chronic pulmonary venous congestion, which ultimately leads to PH. This is thought to be responsible for increased RV after load and subsequent RV dysfunction in these patients. However, some authors had suggested that the direct rheumatic involvement of the RV with resultant myocyte necrosis, replacement fibrosis and calcification is the explanation of such depressed myocardial function.
Effect of balloon mitral valvuloplasty on myocardial mechanics
To the best of our knowledge, ours is the first study to have systematically evaluated the effect of BMV on myocardial deformation (both LV and RV) using STE. BMV resulted in immediate relief of LV inflow obstruction, and the improved hemodynamics were associated with significant increases in both GLS and GCS within 24-48 hours and one month post BMV, Dray et al. reported a case showing improvement in STE-based longitudinal strain in a young girl who underwent BMV.
There was significantly reduced LV GLS in patients with MS compared with healthy controls (−13.10 ± 3.67% vs. −22.17 ± 2.30, P = 0.0001). This is in agreement with the studies of Bilen et al. and Sengupta et al. In order to test an underlying myocardial factor responsible for this decrease, in the present study we compared regional LV longitudinal strain in the study group vs. healthy control group. The presence of significant decrease in LV basal and mid-segmental strain values compared with healthy control group and less or non-significant decrease in apical segments point out to possible underlying myocardial factor where rheumatic endocarditis and scarring extend from the mitral annulus to the surrounding LV segments; an effect that fades away as we go towards the apical segments. This myocardial factor could be the cause of incomplete improvement of the GLS after BMV and act as a contributing factor to the main effect of preload reduction in patients with MS on GLS.
Immediately and one month after BMV, there was significant improvement of LV GLS compared with the same measurements before BMV (post one month − 17.20 ± 3.44 vs. post 24-48 hrs − 14.77 ± 3.98 vs. baseline-13.10 ± 3.67; P = 0.0001). Sengupta et al. also demonstrated significant improvement in LV GLS after BMV compared with the baseline measurements before BMV (−17.8 ± 3.5 vs. −14.6 ± 3.3, P = 0.001). This points out to an underlying haemodynamic factor through the improvement of the LV inflow by relieving the obstruction caused by MS.
This study showed a trend towards normalization of LV GLS compared with the healthy control group after follow-up period of 1 month (−17.20 ± 3.44% vs. −22.17 ± 2.30). Whether this trend will continue on long-term follow-up till the complete normalization of these measurements or the suspected underlying myocardial factor will prevent these variables from complete normalization will need longer term follow-up.
GCS: There was significant improvement of LV GCS, compared with the same measurements before BMV (post one month −28.18 ± 7.10 vs. post 24-48 hrs −24.86 ± 8.23 vs. baseline-19.18 ± 7.58; P = 0.0001). Sengupta et al. also demonstrated significant improvement in LV GCS after BMV compared with the baseline measurements before BMV. Similarly there was significant improvement in LV longitudinal strain, longitudinal strain rate, circumferential strain, circumferential strain rate, regional and global rotation in all LV segments as assessed by STE, immediately i.e. 24-48 hrs after and one month later.
There was significant immediate reduction in LA anteroposterior dimension and LA area. This finding is concordant with a recently published study by Adavane et al, who showed immediate decrease in LA volume after BMV in patients in sinus rhythm. The most valid explanation of this immediate reduction in LA size is decompression of LA and better emptying by releasing the mitral valve obstruction by the BMV.
We also found that there was minor improvement in LV ejection fraction. This correlated with the findings in an earlier study by Mohan et al. The exact reason for this immediate improvement is unclear, but improvement in the atrial contribution to LV filling, 44and improved myocardial contractility45may be the possible explanations. Immediately and one month after BMV, the most important changes were significant improvement in MVA and MG/PG as assessed by 2-D echocardiography compared to patients on medical follow up.
This study also found reduced RV GLS in patients with MS compared with controls (−9.43 ± 5.75 vs. −21.23 ± 6.16). Ozdemir et al. and Kumar et al. also showed decrease in RV GLS in patients with MS compared with control group. There was difference in regional RV longitudinal strain, as seen in significant decrease in the RV strain values of the septal segments, but there was no significant difference between the RV free wall segments, and those in the healthy control group. This is in agreement with the data obtained by Ozdemir et al. and Kumar et al.
This difference may point out to possible underlying myocardial factor where the rheumatic endocarditis and scarring extend from the mitral annulus to the surrounding LV segments and thus reflecting changes actually also occurring in the LV septum and affecting the RV side. This assumption was also adopted by Ozdemir et al. Another assumption for this regional difference in strain values was presented by Kumar et al. who demonstrated that the septum is affected by even moderate degrees of pulmonary hypertension while it needs severe degrees of pulmonary hypertension to affect the RV free wall.
Immediately after BMV, there was significant improvement of the RV GLS compared with the RV GLS before BMV (post one month −17.37 ± 5.72 vs. post 24-48 hrs −13.87 ± 8.93 vs. baseline-9.43 ± 5.75, P = 0.0001). Kumar et al. also demonstrated significant improvement in RV GLS after BMV compared with the baseline measurements before BMV (−11.24 ± 4.24 vs. −9.07 ± 4.7, P = 0.02). This improvement could be due to the improvement in the RV afterload as a result of the relief of the LV inflow obstruction.
This study showed significant improvement of RV GLS compared with the healthy control group immediately after BMV (−13.87 ± 8.93% vs. −21.23 ± 6.16) which continued at follow-up after 1 month (−17.37 ± 5.72 vs. −21.23 ± 6.16). We believe that this improvement is directly related to the significant reduction in both RV volumes as well as RV systolic pressure post-BMV. Immediately and one month after BMV, there was significant improvement in RV longitudinal strain, longitudinal strain rate and regional rotation in all RV segments as assessed by STE as compared to patients on medical follow up. Immediately and one month after BMV, there was significant improvement in severity of TR, PASP as assessed by 2-D echocardiography as compared to patients on medical follow up. Immediately after BMV, there was significant improvement in catheterization parameters (a wave, v wave, EDG, LA mean pressure, LVEDP). These findings are in concordance with the findings with previous studies by Sengupta and Kumar et al.
Thus we have been able to demonstrate that both LV and RV functions assessed by STE and 2D echocardiography are impaired in patient with severe MS compared with healthy controls. There is improvement in these indices after successful BMV with in 24-48 hrs with further improvement after one month. The major contributors to this appeared to be the hemodynamic changes viz. increase in mitral valve area, reduction in LA area, fall in LA pressure with reduction in peak and mean mitral valve gradient as well as fall in PASP and degree of TR.
| Conclusions and Future Implications|| |
Although LV systolic dysfunction in patients with severe MS has been a subject of debate for long but with the advent of STE it has become possible to document LV systolic dysfunction in such patients. Infact, researchers have always been skeptical of deterioration of LV function after MVBD because of this incipient LV dysfunction in these patients. Similarly RV systolic dysfunction, before overt right heart failure develops, has been difficult to evaluate but the development of the technique of ste has provided a simple reproducible tool for assessment of subclinical RV dysfunction. However, the clinical implications of improvements in LV and RV systolic functions remain elusive because of major hemodynamic changes that occur after MVBD that overwhelm these subclinical changes. Although it may be surmised that they should have a salutary impact on clinical outcomes.
Small sample size and observational nature of the study is the limitation of our study. Correlation between severity of MS and improvement in these parameters could not be derived as only severe MS patients were included.
Financial support and sponsorship
Conflicts of interest
This data was presented as abstract in annual conference of European society of cardiology 2016 at Rome, Italy.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]