The prognostic impact of P wave dispersion in prediction of clinical outcome after percutaneous balloon mitarl valvuloplasty in patients with mitral stenosis and sinus rhythm

Ragab A. Mahfouz, Ashraf E. Dewedar

Department of cardiology, Faculty of Medicine, Zagazig University, Zagazig, Egypt.

DOI: 10.4236/wjcd.2013.31014                

Abstract

Objective: The aim of the study was to investigate the impact of P-maximum and P-wave dispersion on the long term clinical outcome after successful percutaneous balloon mitral valvuloplasty (PBMV) in patients with mitral stenosis (MS) and sinus rhythm. Also to test the correlation between P-variables and right ventricular function and pulmonary artery pressure before and after PMBV. Methods: Eighty-five patients undergoing PMBV were enrolled in this study. We evaluated P-maximum, P-minimum and P-wave dispersion before and one month after PBMV. We studied the changes in pulmonary arterial pressure (PAP), left atrial (LA) dimension, mitral diastolic gradient, and mitral valve area, in addition to the changes in right ventricular function utilizing tissue Doppler assessment both before and after PMBV, in addition the role of the P-wave dispersion in predicttion of late cardiac events. Results: There were significant decreases in mean diastolic gradient, PAP, and LA size and significant improvement in right ventricular tissue Doppler indices after PMBV. Ac- company these hemodynamic changes after PMBV. P-maximum and P-wave dispersion were found to be decreased (P < 0.001). Patients developed cardiac events during follow-up had a higher P-maximum and P-dispersion than those without late cardiac events (P < 0.001). Moreover the changes in P-maxi- mum and P-dispersion before and after PMBV in patients with cardiac events were not significant, while P-maximum and P-dispersion significantly (P < 0.002) decreased in patients without events It was revealed with linear regression and correlation analy- sis that the degree of and the changes in P-maximum and P-wave dispersion were correlated with devel- opment of late cardiac events after PMBV, with Cut-off values of ≥62.8 msec for P-wave dispersion and

118 mes for P-maximum.ROC curve showed AUC of 0.919 for P-wave dispersion and 0.913 for P-maximum (P < 0.001). Conclusion: P-wave maximum and dispersion are significantly increased in patients with mitral stenosis. These changes decreased significantly after PMBV. The P-maximum and P-wave dispersion changes were correlated with significant impairment of right dysfunction and the degree of pulmonary artery pressure. P-maximum and P-wave dispersion could be considered as independent predictors of late outcome of patients with MS after successful PMBV (AF, recurrent hospital admission, embolic phenomenon deterioration of right ventricular function).

Keywords

P-Wave Maximum P-Wave Minimum; P-Wave Dispersion; Rheumatic Mitral Stenosis; Cardiac Events; Follow-Up

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Aytemir, K., Ozer, N., Atalar, E., et al. (2000) P wave dispersion on 12-lead electrocardiography in patients with paroxysmal atrial fibrillation. Pacing and Clinical Electrophysiology, 23, 1109-1112. doi:10.1111/j.1540-8159.2000.tb00910.x
[2]	Gialafos, E.J. (1999) P wave dispersion. A valuable electrocardiographic marker for the prediction of paroxysmal lone atrial fibrillation. Annals of Noninvasive Electrocardiology, 4, 39-45. doi:10.1111/j.1542-474X.1999.tb00363.x
[3]	Dilaveris, P.E., Gialafos, E.J., Andrikopoulos, G.K., et al. (2000) Clinical and electrocardiographic predictors of recurrent atrial fibrillation. Pacing and Clinical Electrophysiology, 23, 352-358. doi:10.1111/j.1540-8159.2000.tb06761.x
[4]	Boriani, G., Diemberger, I., Biffi, M., et al. (2005) P wave dispersion and short-term versus late atrial fibrillation recurrences after cardioversion. International Journal of Cardiology International Journal of Cardiology, 101, 355-361. doi:10.1016/j.ijcard.2004.03.039
[5]	Perzanowski, C., Ho, A.T. and Jacobson, A.K. (2005) Increased P-wave dispersion predicts recurrent atrila fibrillation after cardioversion. Journal of Electrocardiology, 38, 43-60. doi:10.1016/j.jelectrocard.2004.09.008
[6]	Palacios, I.F., Sanches, P.C., Harrel, L.C., et al. (2002) Which patients benefit from percutaneous mitral balloon valvuloplasty? Prevalvuloplasty and postvalvuloplasty variables that predict long-term outcome. Circulation, 105, 1465-1471. doi:10.1161/01.CIR.0000012143.27196.F4
[7]	Hernandez, R., Banelos, C., Alfonso, F., et al. (1999) Long- term clinical and echocardiographic follow-up after percutaneous mitral valvuloplasty with the Inoue balloon. Circulation, 99, 1580-1586. doi:10.1161/01.CIR.99.12.1580
[8]	Iung, B., Cormier, B., Ducimetiere, P., et al. (1996) Functional results 5 years after successlful percutaneous mitral commissurotomy in a series of 528 patients and analysis of predictive factors. Journal of the American College of Cardiology, 27, 407-414. doi:10.1016/0735-1097(95)00481-5
[9]	Iung, B., Garbaz, E., Michaud, P., et al. (1999) Late results of percutaneous mitral commissurotomy in a series of 1024 patients. Analysis of late clinical deterioration: Frequency, anatomic findings and predictive factors. Circulation, 99, 3272-3278. doi:10.1161/01.CIR.99.25.3272
[10]	Orrange, S.E., Kawanish, D.T., Lopez, B.M., et al. (1997) Acturial outcome after catheter balloon commissurotomy in patients with mitral stenosis. Circulation, 95, 382-389. doi:10.1161/01.CIR.95.2.382
[11]	Pan, M., Medina, A., Suarez de lezo, J., et al. (1993) Fac- tors determining late success after mitral balloon valvu- lotomy. American Journal of Cardiology, 71, 1181-1185. doi:10.1016/0002-9149(93)90643-Q
[12]	Turhan, H., Yetkin, E., Senen, K., et al. (2002) Effects of percutaneous mitral balloon valvuloplasty on p-wave dis- persion in patients with mitral stenosis. American Journal of Cardiology, 89, 607-609. doi:10.1016/S0002-9149(01)02307-4
[13]	Marijon, E., Jani, D. and Garbarz, E. (2007) P-wave dis-persion and percutaneous mitral valvuloplasty. Cardiology in Review, 15, 42-45.
[14]	Dilaveris, P.E., Gialafos, E.J., Sideris, S.K., Theopistou, A.M., Andrikopoulos, G.K., Kyriakidis, M., Gialafos, J.E., et al. (1998) Simple electrocardiographic markers for the prediction of paroxysmal idiopathic atrial fibrillation. American Heart Journal, 135, 733-738. doi:10.1016/S0002-8703(98)70030-4
[15]	Steban, A., Alia, I., Tobin, M.J., Gil, A., Gordo, F., Vall- verdu, I., Blanch, L., Bonet, A., Vazquez, A., Pablo, R.D., Torres, A., de la Cal, M.A. and Macias, S. (1999) Effect of spontaneous breathing trial on outcome of attempts to discontinue mechanical ventilation. Spanish Lung Failure Collaborative Group. American Journal of Respiratory and Critical Care Medicine, 159, 512-518.
[16]	Ghio, S., Recusani, F., Klersy, C., Sebastiani, R., Laudisa, M.L., Campana, C., Gavazzi, A. and Tavazzi, L. (2000) Prognostic usefulness of the tricuspid annular plane sys- tolic excursion in patients with congestive heart failure secondary to idiopathic or ischemic dilated cardiomyo- pathy. American Journal of Cardiology, 85, 837-842. doi:10.1016/S0002-9149(99)00877-2
[17]	Vignon, P., AitHssain, A., Fran?ois, B., Preux, P.M., Pichon, N., Clavel, M., Frat, J.P. and Gastinne, H. (2008) Echocardiographic assessment of pulmonary artery occlusion pressure in ventilated patients: a transoesophageal study. Critical Care, 12, R18. doi:10.1186/cc6792
[18]	Mehta, C.R. and Patel, N.R. (1995) Exact logistic regression: Theory and examples. Statistics in Medicine, 14, 2143-2160.
[19]	Hanley, J.A. and McNeil, B.J. (1982) The meaning and use of the area under a receiver operating characteristics (ROC) curve. Radiology, 143, 29-36.
[20]	Andrikopoulos, G.K., Dilaveris, P.E. and Richer, D.J. (2000) Increased variance of the P wave duration on the electrocardiogram distinguishes patients with idiopathic paroxysmal atrial fibrillation. Pacing and Clinical Electrophysiology, 23, 1127-1132. doi:10.1111/j.1540-8159.2000.tb00913.x
[21]	Braunwald, E. (2001) Valvular heart disease. In: Braun- wald, E., Zipes, D.P. and Libby, P., Eds, Heart Disease: A Text book of Cardiovascular Disease, 6th Edition, WB Saunders, Philadelphia, 1643-1653.
[22]	Chandrasekar, B., Loya, Y.S., Sharma, S., et al. (1998) Acute effect of balloon mitral valvotomy on serial electrocardiographic changes and their haemodynamic correlation. Indian Heart Journal, 50, 179-182.
[23]	Dogan, A., Avsar, A. and Ozturk, M. (2004) P-wave dispersion for predicting maintenance of sinus rhythm after cardioversion of atrial fibrillation. American Journal of Cardiology, 93, 368-371. doi:10.1016/j.amjcard.2003.09.064
[24]	Ciaroni, S., Cuenoud, L. and Bloch, A. (2000) Clinical study to investigate the predictive parameters for the on- set of atrial fibrillation in patients with essential. American Heart Journal, 139, 814-819. doi:10.1016/S0002-8703(00)90012-7
[25]	Agarwal, Y.K., Aronow, W.S. Levy, J.A. and Spodick, D.H. (2003) Association of interatrial block with development of atrial fibrillation. American Journal of Cardiology, 91, 882. doi:10.1016/S0002-9149(03)00027-4
[26]	De Bacquer, D., Willekens, J. and De Backer, G. (2007) Long-term prognostic value of p-wave characteristics for the development of atrial fibrillation in subjects aged 55 to 74 years at baseline. American Journal of Cardiology, 100, 850-854. doi:10.1016/j.amjcard.2007.04.017
[27]	Erbay, A.R., Turhan, H., Yasar, A.S., et al. (2005) Effects of long-term beta-blocker therapy on P-wave duration and dispersion in patients with rheumatic mitral stenosis. International Journal of Cardiology, 102, 33-37. doi:10.1016/j.ijcard.2004.03.079