Left Atrial Appendage Emptying Velocity and Coexisting Echocardiographic Findings in Severe Rheumatic Mitral Stenosis: A Single-Centre Cross-Sectional Observational Study

Q: What are the key findings of this study?

Patients with severe rheumatic mitral stenosis exhibited left atrial appendage emptying velocity <30 cm/s in 58% of cases, alongside atrial fibrillation (58%), SEC (64%), and LAA thrombus (30%).

Q: What is the clinical evidence from this study?

Study design: Cross-Sectional. Population: Severe rheumatic mitral stenosis (n=50). Intervention: Severe rheumatic mitral stenosis undergoing transoesophageal echocardiography. Primary outcome: Left atrial appendage emptying velocity (LAAEV) <30 cm/s (95% CI 43.2-71.8%).

Q: What does this research mean for the field?

A majority of patients with severe rheumatic mitral stenosis exhibit reduced left atrial appendage emptying velocity (<30 cm/s), alongside high frequencies of atrial fibrillation, spontaneous echo contrast, and left atrial appendage thrombus. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Salman Khalid; Muhammad Shuaib Abid; Dr. Usman Sajid; Amjad Ali

doi:10.47144/phj.v59i5.3882

September 25, 2026Pakistan Heart JournalOpen Access

Left Atrial Appendage Emptying Velocity and Coexisting Echocardiographic Findings in Severe Rheumatic Mitral Stenosis: A Single-Centre Cross-Sectional Observational Study

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Key result

Severe rheumatic mitral stenosis is linked to depressed LAA emptying velocity in ~58% of patients.

95% CI 43.2-71.8%
n=50

Why the study?

The study aimed to describe the distribution of LAAEV and the coexistence of AF, SEC, and LAA thrombus among patients with severe rheumatic mitral stenosis undergoing TEE.

Key Points

To describe the distribution of left atrial appendage emptying velocity (LAAEV) and the coexistence of atrial fibrillation, spontaneous echo contrast, and left atrial appendage thrombus in patients with severe rheumatic mitral stenosis.
Single-centre, cross-sectional observational study of 50 consecutive adult patients with severe rheumatic mitral stenosis (mitral valve area ≤1.5 cm²) undergoing clinically indicated transoesophageal echocardiography in Pakistan.
LAAEV was evaluated using pulsed-wave Doppler and categorized a priori (<20, 20–29, 30–39, and ≥40 cm/s), alongside documentation of atrial fibrillation, spontaneous echo contrast, and left atrial appendage thrombus.
Predefined LAAEV was <20 cm/s in 18 patients (36%; exact 95% CI: 22.9–50.8%), 20–29 cm/s in 11 (22%; exact 95% CI: 11.5–36.0%), 30–39 cm/s in 21 (42%; exact 95% CI: 28.2–56.8%), and <30 cm/s overall in 29 patients (58%; exact 95% CI: 43.2–71.8%), with 0 patients presenting with LAAEV ≥40 cm/s.
Atrial fibrillation was present in 29 patients (58%; exact 95% CI: 43.2–71.8%), spontaneous echo contrast was identified in 32 (64%; exact 95% CI: 49.2–77.1%), and left atrial appendage thrombus was detected in 15 (30%; exact 95% CI: 17.9–44.6%).

Study Design

Type

Cross-Sectional (n=50)

Multicenter

No

Structured PICO

P

Population

50 predominantly female (90%) adults (mean age 37.3 years) with severe rheumatic mitral stenosis (MVA ≤1.5 cm²) without previously known LAA thrombus or prosthetic mitral valve undergoing clinically indicated transoesophageal echocardiography in a cross-sectional study.

E

Exposure

Clinically indicated transoesophageal echocardiography (TEE) with pulsed-wave Doppler assessment of left atrial appendage emptying velocity (LAAEV)

O

Outcome

Distribution of predefined left atrial appendage emptying velocity (LAAEV) categories (<20, 20–29, 30–39, and ≥40 cm/s) and coexistence of atrial fibrillation (AF), spontaneous echo contrast (SEC), and left atrial appendage (LAA) thrombus during cross-sectional TEE assessmentsurrogate

In a young, predominantly female Pakistani cohort with severe rheumatic mitral stenosis undergoing clinically indicated TEE, reduced left atrial appendage emptying velocity (<30 cm/s in 58%) frequently coexisted with atrial fibrillation (58%), spontaneous echo contrast (64%), and left atrial appendage thrombus (30%).

Limitations

Single-centre cross-sectional design with a small pragmatic sample size of 50 participants and no formal a priori sample-size calculation.
Potential referral and selection bias due to recruiting only patients undergoing clinically indicated TEE at a tertiary cardiac centre, and exclusion of patients with previously documented LAA thrombus.
Patient-level continuous LAAEV measurements and verified joint subgroup coding were not retained, preventing correlation analyses, subgroup hypothesis testing, or multivariable modelling.
Absence of key clinical and haemodynamic variables (e.g., left atrial volume, transmitral gradient, anticoagulation status, prior stroke) limiting assessment of confounding.
Missing technical TEE details, lack of blinded independent image assessment, no intraobserver or interobserver reproducibility evaluation, and no longitudinal follow-up for clinical outcomes.
Relatively small single-centre sample (n=50) without a formal a priori sample-size calculation
Referral and selection bias cannot be excluded because only patients undergoing clinically indicated TEE at a single tertiary-care centre were included
Exclusion of patients with LAA thrombus already documented before enrolment may have underestimated the overall prevalence of LAA thrombus
Patient-level continuous LAAEV measurements and joint subgroup coding were not retained, precluding correlation analyses, subgroup hypothesis testing, and multivariable modelling
Formal blinded independent image assessment and intraobserver/interobserver reproducibility were not evaluated, and several relevant clinical/haemodynamic variables (e.g., LA size, transmitral gradient, anticoagulation status) were unavailable

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Implication

May support TEE evaluation in severe rheumatic mitral stenosis; leaves open LAAEV thresholds for embolic risk stratification.

Abstract

Objectives: To describe the distribution of left atrial appendage emptying velocity (LAAEV) and the coexistence of atrial fibrillation (AF), spontaneous echo contrast (SEC), and left atrial appendage (LAA) thrombus among patients with severe rheumatic mitral stenosis undergoing transoesophageal echocardiography (TEE). Methodology: This single-centre, cross-sectional observational study included 50 consecutive adults with severe rheumatic mitral stenosis who underwent clinically indicated TEE at the Department of Cardiology, Punjab Institute of Cardiology, Lahore, Pakistan, between 21 May and 31 July 2026. Severe rheumatic mitral stenosis was defined by characteristic rheumatic valve morphology and a mitral valve area ≤1.5 cm² measured using two-dimensional echocardiographic planimetry. LAAEV was assessed using pulsed-wave Doppler and categorized a priori as <20, 20–29, 30–39, and ≥40 cm/s for descriptive purposes. AF, SEC, and LAA thrombus were also recorded. Results: The mean age of participants was 37.3 ± 9.4 years; 45 (90%) were female, and the mean mitral valve area was 1.01 ± 0.22 cm². LAAEV was <20 cm/s in 18 patients (36%; 95% CI: 22.9–50.8%), 20–29 cm/s in 11 (22%; 95% CI: 11.5–36.0%), and 30–39 cm/s in 21 (42%; 95% CI: 28.2–56.8%); no participant had an LAAEV ≥40 cm/s. Overall, 29 patients (58%; 95% CI: 43.2–71.8%) had LAAEV <30 cm/s. AF was present in 29 patients (58%; 95% CI: 43.2–71.8%), SEC in 32 (64%; 95% CI: 49.2–77.1%), and LAA thrombus in 15 (30%; 95% CI: 17.9–44.6%). Conclusion: Lower predefined LAAEV categories were frequently observed in this cohort of patients with severe rheumatic mitral stenosis, alongside substantial frequencies of AF, SEC, and LAA thrombus. These findings are descriptive and do not establish statistical association, prediction, causality, or prognostic utility. Larger prospective studies retaining continuous patient-level LAAEV measurements and longitudinal thromboembolic outcomes are warranted.

Discussion

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Cite This Study

Khalid et al. (2026) conducted a cross-sectional in Severe rheumatic mitral stenosis (n=50). Severe rheumatic mitral stenosis undergoing transoesophageal echocardiography was evaluated on Left atrial appendage emptying velocity (LAAEV) <30 cm/s (95% CI 43.2-71.8%). Patients with severe rheumatic mitral stenosis exhibited left atrial appendage emptying velocity <30 cm/s in 58% of cases, alongside atrial fibrillation (58%), SEC (64%), and LAA thrombus (30%).

synapsesocial.com/papers/6af0dba03c845ca7837cedb3 https://doi.org/10.47144/phj.v59i5.3882

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Left Atrial Appendage Emptying Velocity and Coexisting Echocardiographic Findings in Severe Rheumatic Mitral Stenosis: A Single-Centre Cross-Sectional Observational Study

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Left Atrial Appendage Emptying Velocity and Coexisting Echocardiographic Findings in Severe Rheumatic Mitral Stenosis: A Single-Centre Cross-Sectional Observational Study

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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