Download Normal Left Atrial Pressure

The Syndrome of Severe Mitral Regurgitation with
Normal Left Atrial Pressure
By
EUGENE BRAUNWALD,
M
.D.,
WILLIAM C. AWE, M.D.
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of them. All ten patients were severely disabled
and were considered, on clinical grounds, to be in
functional classes III or IV (New York Heart
Association). The patient with congenital mitral
regurgitation had symptoms for 1 year, whereas
the other patients had symptoms for 4 to 19 years
(average of 9.3 years). All patients complained of
severe fatigability and various degrees of exertional dvspnea. Symptoms or clinical signs of left
ventricular failure had been present for 1 to 8
years (average of 3.2 years). All 10 patients were
receiving maintenance digitalis therapy at the
time of study and had been receiving this medication for 1 to 33 years (average of 7.4 years).
Five patients had experienced paroxvsmal nocturnal dyspnea, two of them had had hemoptvses,
and five had had ankle edema.
Physical Examination
All 10 patients had prominent left ventricular
lifts and in five of tlhem a strong svstolic thrill
was palpable at the apex. A holosystolic murmur,
of at least grade III/VI intensity, was heard at
the apex and was transmitted into the axilla in
all 10 patients, and nine of them also had tie
short, low-pitched, mid-diastolic murmur at the
apex, which is typically heard in patients Witll
severe mitral regurgitation.'6 Hepatomegaly and
edema were present in only three instances. None
of the patients had clinical or laboratory evidence
suggestive of active rheumatic fever at the time
of study.
Electrocardiograms
All 10 patients exhibited atrial fibrillation. Riglit
axis deviation was present in one patient, while
in the other nine the electrical axis was normal.
The voltage criteria for left ventricular hvpertrophyv were satisfied in seven patients.
IT HAS BEEN demonstrated repeatedly
that when mitral regurgitation is produced
in experimental animals, an elevation of left
atrial pressure occurs.1-3 Similarly, numerous
hemodynamic studies in patients with this
valvular lesion have shown that the left
atrial413 or pulmonary artery wedge pressures'14 15 generally exceed the values observed
in normal individuals, and the V-wave peaks
in these pressure pulses are particularly prominent. These pressure elevations have been
attributed to the increased volume of blood
that enters the left atrium during ventricular
systole.1 6 Indeed, elevation of the mean left
atrial pressure with particularly tall V waves
has become the hemodynamic hallmark of mitral regurgitation, and the diagnosis of this
abnormality by cardiac catheterization has
been based, in large measure, on these characteristic pressure changes. It is the purpose
of this report to focus attention on a group
of patients with severe mitral regurgitation
in whom these alterations in the left atrial
pressure pulse are not evident, and who appear to constitute a distinct segment in the
clinical-hemodynamic spectrum of mitral regurgitation.
Description of Patients
Studies on a total of 10 patients constitute the
basis of this report. Congenital mitral regurgitation was present in one patient, an 8-year-old
girl. The other nine patients (seven women and
two men) have acquired rheumatic mitral valvular regurgitation. These nine patients ranged in
age from 27 to 49 years, with an average age of
39 years.
History
A history of active rheumatic fever was elicited
from all nine patients with rheumatic mitral regurgitation, and multiple attacks occurred in seven
Roentgenograms
Gross cardiac enlargement was evident on the
chest roentgenograms of all 10 patients. The left
atrium was considered to be nmoderately enlarged
in three patients, and markedly enlarged in the
remainder (fig. 1). Although it was difficult to
define the presence or absence of left ventricular
enlargement, this chamber was considered to be
enlarged in eight of the 10 patients.
Hemodynamic Studies
The pulmonary artery or right ventricular svs-
From the Cardiology Branch and the Clinic of
Surgery, National Heart Institute, Bethesda, Maryland.
Circulation, Volume XXVII, January 1963a
AND
29
BR3AUNW Alj1). A \V E
30
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Figure 1
r -dreifpt1qit(oifJo. mrked left atiail enlaJ -.?Rovean tgenoyrams of patient.s with sel itrmitrl
mnto t. oad nortttol left atril pXressre..
tolic pressures were witlhin norimial limits for this
laboratory (under 30 inni. Hg) in all, except
patient R.F. (table 1). The miiean pulmonary
artery pressures ranged from-: 13 to 22 mm. Hg.
Left atrial pressures. miieasured bv the transseptal17 or transbronchial'8 teehnies, were within the
normaal range for this laboratorvI9 (table 1 and
figs. 2 and 3). The V-wave peaks were minimally
elevated in only three patients, amid were within
nonral limits in the other seven patients. The
left ventricular end-diastolic pressure ranged froml
2 to 13 mm. Hg. Cardiac output measured by
the indicator-dilution technic was abnormallv low
in five of seven patients. In eight of the patients
indicator-dilution curves recorded from a svstemic artery following injection into the left ventricle or left atrium were eharacteristic of muitral
regurgitation (fig. 3).
Pathologic Data
Nine of the 10 patients included in this report
are alive, so that pathologic data are available
on one patient (S.H.). In this 8-year-old girl
the left ventricle was hypertrophied, and the left
atrium was markedly dilated. The anterior mitral
leaflet was shortened, and the chordae tendineae
to both leaflets were markedlv shortened, preventing valve closure.
Discussion
The hemodynamie findings ill patients with
iititral regurgitation have been well documented.4 15 In patients in whom this is the
predominaiit valvular lesion. and who exhibit.
congestive heart failure or symniptomxls of di
minished cardiac reserve, the cardiac output
has frequenitly been noted to be below normal.
the mean left atrial pressure elevated, anid the
'V'-wave peaks have been particularly high
In a signlificant number of such patients, the
pulmonary artery pressure is elevated proportionately inuore than the left atrial pressure
due to associated elevations of the pulnmonarv
vascular resistance. In this latter group of
patients clinical inanifestatioiis of right heart
failure are not untusual.5 20
Perusal of the published clinical and hemodynamic data obtainied from patienits with
mitral regurgitation has re-vealed an occasional exception to this pattern. In each of
several series of patients with this valvular
abnormality there have been one or two patients who evidently exhibited clinical maniiCirculation TVofume XXVII
Tanutary 196i.
31
SEVERE MITRAL REGURGITATION
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festations of reduced cardiac reserve and who
had left atrial enlargement but in whom the
left atrial (or pulmonary artery wedge) pressures were within normal limits.8' 10, 13, 20 The
data obtained from the patients described in
this report focus attention on the syndrome
of severe mitral regurgitation with normal
left atrial pressure. On clinical grounds, all
10 of these patients had a markedly reduced
cardiac reserve, and several were considered
to be approaching the termination of their
illness. With the exception of the child with
congenital mitral regurgitation, the other nine
patients had symptoms for many years. The
chronicity of the process was also reflected in
the atrial fibrillation in all 10 patients. The
clinical findings characteristic of mitral regurgitation were unequivocal, and there was
no clinical or hemodynamic evidence of any
associated cardiovascular abnormality. Whereas other series of patients with rheumatic
mitral regurgitation have had a preponderance of male patients,21-23 seven of the nine
patients with rheumatic heart disease included
in this report were female. Although a history
of active rheumatic fever has been reported
in 25 to 50 per cent of patients with chronic
mitral regurgitation,8 22 it could be elicited in
all nine patients with rheumatic mitral regurgitation reported herein. Atrial fibrillation
and gross left atrial enlargement were present
Figure 2
Left atrial (LA)
pressure
pulse of patient I.H.
in all 10 patients. Although absolute measurements of mitral regurgitant flow in man are
not feasible, the contour of the arterial indicator-dilution curves following injection into
the left side of the heart were suggestive
of massive regurgitation (fig. 3)..
If the compliance of the left atrium remained constant, enlargement of this chamber
could occur only in association with an increase in the transmural pressure. The association of a normal mean left atrial pressure
and a normal left atrial V wave, with a
markedly enlarged left atrium indicates that
the walls of the left atrium and of the pulmonary venous bed are more compliant than
Table 1
Hemodynamic Findings
PA
Age, yrs.,
Patient
sex
S/d, mean
mm. Hg
LA, mean
mm. Hg
LA, "V"
wave peak
mm. Hg
LA-LV
LVED
mm. Hg
end-diast.
grad.
mm. Hg
Cardiac index
L./min./M.2
1
1.21
6
11
23
27/
43, F
L.P. no. 00-82-40
1.73
5
11
3
0
25/7 (13)
P.K. no. 02-68-76
44, F
3
1.07
8
11
3
25/9 (15)
H.E. no. 02-55-35
45, F
2
2.68
16
7
10
27/5 (18)
49, F
I.R. no. 03-38-41
..
2.53
14
7
28/10 (20)
40, F
A.P. no. 01-25-02
22
0
12
4
32/14 (22)
R.F. no. 03-29-28
47, M
22
0
1.40
12
7
28/9 (19)
38, F
E.C. no. 03-75-61
2
15
13
9
26/10 (20)
R.G. no. 02-96-85
24, F
12
2
3
3.30
9
25/10 (18)
B.R. no. 03-88-86
27, M
14
0
8
7
S.H. no. 03-07-20
28/12 (20)
8, F
PA, pulmonary artery pressure; S/d, m, systolic/diastolic, mean pressures, LA, left atrial pressure; LVED,
left ventricular end-diastolic pressure; LA-LV end-diast. grad., left atrial-left ventricular end-diastolic pressure
gradient.
Circulation, Volume XXVII, January 1963
32
2BRAITINWALD, AN\V
SH #03-07-20
72706
LA !NJ
LVI
Hg
24
2~
Figure 3
(Ieft)
o
n
t(i0
itin0
s
lov<ing
ecoi
(-id((cthieter
le(/
withdr(11v01(
from left ventricle (LV) to lett
(tl (niu in p ottiet S.1I . Note tli
vle ( of left
atrial press-ire an1d the absence of a p2iessure
gradie-nt across the ioitral l(cclve. Thei ilidici1to1dilation1 0/liC.e on? the right
recordedfironm the
brachial arlter!y folliorItlfin jectiOnl i) t O the left
111s
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was
a t rin (m.
usual in the patients described herein. It is
s-uggested that long-standing mnitral regurgitation may, in some instances, alter the lengthtension characteristics of the left atrial wall
alid therely displace the atrial pressure volnine curve to make it more complianit. so that
a niormal pressure exists in a greatli- enilarogd
atrium.
The possibility that alterations in the pressure-voluimne relationships of the left atriumi
m-ay oceur is not a new coneept. It has been
postulated by a number of investigators that
differenices in atrial comipliance ocecir among
dlifferent patients witlh mitral valvex disease0' 13 20, 24-26 Indeed, the difficulties encounitered with analvses of the left atrial
pressiure pulse contouir for the separatiomi of
patients withl mtitral stenosis froni tihose withi
mlitral reg;urgitation ha>ve been attriblnted to
variatiomis in the pressure-volume relationships Hin the left atrin-i amid tIme pull-moiary
ve-lIus bede6 Although it is possible that chron-iie aetive
rheumatic fever played a role in time alterationis of the umechanical properties of tIhe left
atriumi. it is evident tliat, since one of the
patients( S.H.) haad congenital ratlher thami
:rheummatie) disease, the presence of lheumiatic
aetiviti is certainl1 not essential to the devel-
opmetit of the sv ldromle describedl. Furtfiei
milore, none of the nine patienits w:ithi rhen-niatie; umitral regurgitation (cI bIte( anv
clinieal or laboratory finidings tlhat sniggeste(
the presenee of rheumyiatie aetivity. Sincee all
of the patienits had had mlitral regurgoitatio)n
for manyr years, it is likely that the chlanges
ini atrial distensibility that wvere present lfl
thle timne of study had niot beeln present earlier.
but had(leveloped duninig the course of the illness. 1 nfortunmately, serial incasuellntents of
a tral )pressure lad u-ot been (arr-i 'ed ontt on
a,- of thtese
latielilts. Studies on a patie-nt
n-iot inielucled in this series.2 r ide
s(tro::ll
suggestive evidenee tfiat tlie inc(-rease in atrial
couliplianlee muay Oldr as a late dcvelopmient
iii the eourse of elron:ie initral recurgitatiolln
Tjiis 9-vear-old boy (levelopedl exertiomal
dvspnea at the age of S yeairs and exainina'Itioii at this time revealed that hie had a ret(u-m
lar rlythm and the physieal findinigs efiar-ae,
teristie of mi-tral recfurgitation. Right heart
(athiete rizationi, r --Ivealed elevationi of tile pul
40
monarv arterv pjressure 'S/30, m1-ean
ina. Ji r? and transseptal left lheart eatheterizatio0 shiow(-e,d thie left atrial press-ure to be, ed
VaI ted
C'IsAsTwell I" m-lean- t21 nlm. HI-, V peak:
45) nuns. Ei )Y. The lpatient s syniptomns of eo-ne,stiveiheart failure increased in severity in
s];)ite ofr intelisive thelrapv and I vear after
thlese,i studies his cardiae rhythmn changed to
atrial fibril lation. There was roentgenographie
evidence of further increase in the size of tIme
left atriui, bhut surprisinclv, the left atria]
(gI> eani
pressure liad declined cluite strikinigly
15) nim. Hig. V peak - 24 mlm. Ig). Thus,
in tfiis patieilt a decline in the imean- left
atrial pressu.re an-id tlhe atrial V-wave pealk
)resltXle oeciUre(nr in the faee of ani. increase
in left atrial size. Since he slhimved striking
Tlin ial imnprovemenit a fter operatioin whicel
aNl (lts
accomipanied b)yr a further decline. of
atrial pressure to a mnean of 7 iim. Hg, as
xvelI as sponta:neous reversioni to si4nus rhythmi,
it would appear that the imierease in atrial
eomnplianice is not necessarilv aecoipanied by
irreversible depression of left venitricular
functioni. The presenee of atrial fibrillation ini
thle 10 patients (described herein. as well as
I i,J (tv
Crculautieon, Volume XX
el(try i96A
SEVERE MITRAL REGURGITATION
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the transient period of fibrillation in patient
A.J. discussed above, suggests the possibility
that the process that changed atrial compliance may also have been related in some fashion to the development of this arrhythmia.
The compliance of the left atrium and pulmonary venous bed appears to be capable of
modifying profoundly the clinical and hemodynamic picture exhibited by patients with
mitral regurgitation. On the basis of differences in atrial compliance, three major groups
of patients with mitral regurgitation can be
identified: 1. A group of patients with mild
or moderate enlargement of the left atrium,
but with quite striking elevation of the mean
left atrial pressure, and particularly of the V
wave. In many patieiits in this group, severe
mitral regurgitation has developed acutely,
as for example those in whom there occurs
sudden rupture of chordae tendineae or a tear
of a mitral leaflet (fig. 4). Marked elevation
of pulmonary vascular resistance occurs with
considerable frequency in this group of patients, and therefore right heart failure is
not an unusual clinical manifestation.8 2. By
far the most common group of patients with
mitral regurgitation is represented by those
with moderate or massive enlargement of the
left atrium, associated with significant elevations of the left atrial pressure. 3. The third
group of patients in this spectrum is represented by the patients with the syndrome of
severe chronic mitral regurgitation and normal left atrial pressure described in detail
in the present report. It seems likely that these
three groups form a continuum and that
numerous gradations exist between them.
Since effective surgical treatment for mitral
regurgitation is now becoming a reality,28 29
some comment is warranted on how the variations of left atrial compliance, and the resultant clinical-hemodynamic findings modify
the selection of patients. Since, with any given
magnitude of regurgitant flow the atrial pressure varies inversely with the compliance of
the atrium, the extent to which the atrial
pressure can be expected to decline following
successful operation will also vary inversely
with atrial compliance. Accordinigly, the cliniCirculation, Volume XXVII, January 1965
B.
MM. Hg
[-0.3 sec.-i
Figure 4
Chest roentgenogram (Top) and left atrial (LA)
pressure pulse (Bottom) obtained from a 23year-old woman who suddenly developed mitral
regurgitation two months before these studies during the course of acute bacterial endocarditis.
Although the left atrial enlargement is similar in
degree to that exhibited by many of the patients
described in this report, note the elevated lef t
atrial pressure with particularly tall V waves.
cal and hemodynamic benefits of operation
may be expected to be greatest in the patients
with relatively small left atria and high left
atrial pressures. Conversely, the benefit in
the patients described in this report would
not be expected to be as striking, since their
left atrial pressures cannot decline to any significant extent. By diminishing the hemodynamic burden imposed on their left ventricles, however, operation may be expected
to elevate the low cardiac outputs in these
34
patients. Indeed, a number of observations
suggest that operative intervention should
also be considered in patients with the syndrome of severe mitral regurgitation and normal left atrial pressure. Among these are (1)
the favorable effects of operation in patient
A.J. described above, (2) the fact that patient S.H. succumbed to chronic congestive
heart failure in spite of the finding of a normal atrial pressure at catheterization carried
out several months earlier, and (3) the faet
that these patients, in spite of normal atrial
pressures, were all incapacitated.
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Summary
It has been generally thought that significant elevations of the left atrial and pulmonary vascular pressures occur in patients with
mitral regurgitation of sufficieint severity to
produce serious disability and gross enlargement of the left atrium. Ten patienits with
severe mitral regurgitation have been encountered in whom gross left atrial enlargement
was accompanied by normal left atrial and
pulmonary artery pressures. These patients
ranged in age from 8 to 49 years, all were in
functional classes III or IV, atnd the average
duration of symptoms was 7.3 years. Nine
patients had rheumatic mitral regurgitation
while one had a congenital lesion. Atrial
fibrillation and the physical findings of pure
mitral regurgitation were presenlt in all patients, as was striking left atrial enlargement
on their roentgenograms. Left atrial pressure.
determined by left heart catheterization, averaged 9.1 mm. Hg and did niot exceed 12 mmn.
Hg in any patienit, and the V wave was not
particularly prominent. The eardiae index
was markedly depressed aind averaged 2.0
L./min./M.2 B.S.A.
The observed discrepancy between left
atrial size and pressure must reflect a disturbance in the compliance of the left atrial
wall. It is suggested that long-standing mitral
regurgitation may modify the meehanieal
characteristics of the atrial wall and that the
presence of a normal left atrial pressure must
not be assumed to exclude the presence of
severe mitral regurgitation. The manner in
BRAUNWVALD, AWE
which variations in left atrial compliance
affect the clinical picture of mitral regurgi
tation and the selection of patienits for operative intervention are diseussed
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Training the Doctor of Tomorrow
In matters of health and medical care, the doctor no longer stands alone. He continues to be the leader and captain of the team, or teams, but he is assisted by at least
132 groups who have been specially trained in careers of health service. There are in
the United States 2,500,000 people engaged in the so-called health professions. Today,
doctors do many things. There are thousands of doctors who are never seen at a
patient's bedside. Dr. A travels to the hospital administrator's office or to the Dean's
office with a brief case; Dr. B spends his working life amid test tubes; Dr. C. is a
detective who can tell whether a woman was hanged or strangled; and Dr. D. tests
whether atom scientists have absorbed excessive radiation. Thus, I could go on and
on, down the alphabet several times. The doctors who treat patients, however, whether
in their offices or at the bedside, are the men responsible for the doctor-patient relationships and are largely responsible for the public attitudes about the profession.-CHESTER
S. KEEFER, M.D. Training the Doctor of Tomorrow, Boston, The Boston Medical
Quarterly 12: 87, 1961.
Circulation, Volume XXVII, January 1963
The Syndrome of Severe Mitral Regurgitation with Normal Left Atrial Pressure
EUGENE BRAUNWALD and WILLIAM C. AWE
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Circulation. 1963;27:29-35
doi: 10.1161/01.CIR.27.1.29
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 1963 American Heart Association, Inc. All rights reserved.
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