Cardiac MRI in rheumatic heart disease patients with significant Left ventricular dysfunction

摘要

Background: Rheumatic heart disease (RHD) is the most commoncause of valvular heart disease in India and other developingcountries accounting for 25-45% of acquired heart disease. RHDespecially regurgitant lesions of mitral and aortic valve and Aorticstenosis are associated with left ventricular systolic dysfunctionlater in their natural history. It is not clear based on present data,whether this LV dysfunction is fully reversible if the mechanicalcomponent is corrected by surgery. Cardiac magnetic resonanceimaging (MRI) to detect significant myocardial fibrosis may helpdetecting patients with irreversible myocardial dysfunction withpoor recovery of LV function after surgery.Methods:We retrospectively reviewed the records of RHD patientswith LV (Left ventricular) dysfunction (Left ventricular ejectionfraction, LVEF < 50%) by echocardiogram who underwent CardiacMRI. Patients with history or any evidence of previous acute coronarysyndrome or coronary artery disease, any other cardiomyopathieswere excluded. We analysed what percentage of thesepatients had significant late gadolinium enhancement (LGE) suggestiveof fibrosis on cardiac MRI, whether there was any correlationof LGE with the degree of LV dysfunction and whether anyspecific pattern of LGE was present in RHD patients.Results: Cardiac MRI data of 17 patients (14 (82%) male) with meanage 47.8 years (range 29-61) were analysed. 15 of the 17 patients underwent a coronary angiogram which was normal. 14 patients(82%) had mitral valve disease (78% of whom had dominant mitralstenosis with mild or no regurgitation, 22% had atleast moderatemitral regurgitation), 3 patients has significant combined valvedisease. Six patients (35%) had mild LV dysfunction (LVEF 41-50%),9 patients (52%) had moderate LV dysfunction (LVEF 31-40%) and 2patients (13%) had severe LV dysfunction (LVEF 30%). Thirteenpatients (76%) were in atrial fibrillation and 4 patients (24%) werein sinus rhythm. There was a good correlation between echocardiographicand Cardiac MRI derived LVEF (Correlation coefficient0.82). Only 2 of the 17 patients showed myocardial LGE. There wasno correlation between the LVEF and presence of LGE. One patientshad subendocardial and midmyocardial enhancement ofInferoseptum and one had enhancement of papillary muscles.LGE of valves was observed in 16 out of 17 patients (mitral valve in94%, aortic valve in 35% and tricuspid valve in 29% patients).Enhancement of the Left atrial wall or interatrial septum was seenin 7 patients (41%), six of whom had atrial fibrillation.Conclusion: This study shows that majority of RHD patients withLV dysfunction, even those with severe LV dysfunction have nomyocardial fibrosis as indicated by LGE on cardiac MRI suggestinggood LV function recovery after valve surgery. Prospective studieswith larger sample size with postoperative follow-up are requiredto confirm these findings.