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Lutembacher's syndrome - Wikipedia

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Lutembacher's syndrome is a form of congenital heart disease. Lutembacher's syndrome

was first described by a French cardiologist by the name of René Lutembacher (1884–
1968)[1] of Paris, France in 1916.[2] Lutembacher syndrome is a rare disease that affects one
of the chambers of the heart as well as a valve of the heart. Lutembacher's syndrome is
known to affect females more often than males.[3] Lutembacher is an extremely rare
disease.[3] Lutembacher's can affect children or adults; the person can either be born with the
disorder or develop it later in life.

Lutembacher affects more specifically the atria of the heart and the mitral or bicuspid valve.
The disorder itself is known more specifically as both congenital atrial septal defect (ASD)
and acquired mitral stenosis (MS).[2] Congenital (at birth) atrial septal defect refers to a hole
being in the septum or wall that separates the two atria; this condition is usually seen in
fetuses and infants.[4] Mitral stenosis refers to mitral valve leaflets (or valve flaps) sticking to
each other making the opening for blood to pass from the atrium to the ventricles very
small.[5] With the valve being so small, blood has difficulty passing through the left atrium
into the left ventricle. There are several types of septal defects that may occur with
Lutembacher's syndrome: ASD Ostium Secundum or ASD (Primium); Ostium Secundum is
the most prevalent.[3]

To correct Lutembacher's syndrome, surgery is often done. There are several types of
surgeries depending on the cause of Lutembacher's syndrome(ASD Primium or ASD Ostium
Secundum with Mitral Stenosis):

1. Suturing (stitching) or placing a patch of tissue (similar to skin grafting) over the hole
to completely close the opening
2. Reconstructing of the mitral and tricuspid valve while patching any holes in the heart
3. Device closure of ASD (e.g. Amplatzer umbrella or CardioSEAL to seal the hole[2][6]
4. Percutaneous transcatheter therapy[2]
5. Transcatheter therapy of balloon valvuloplasty to correct MS[2]

Symptoms[edit]
As Lutembacher's syndrome is known for ASD and MS, most of the symptoms experienced
will be associated with ASD and MS. For most people, they will remain asymptomatic
(experience no symptoms) but when symptoms are shown, they are due mainly to ASD and
will vary depending on the size of the hole in the atria. If the patient has a large ASD,
pulmonary congestion (blood or fluid buildup in the lungs) will happen later but if the patient
has a small ASD, symptoms will appear early in the disorder. In general, unless the ASD and
mitral stenosis causing Lutembacher's syndrome is severe, symptoms may not appear until
the second and third decade of the patient's life.[6] As many of the symptoms are asymptomic
and may not appear until later in life, the duration or frequency of the symptoms varies. For
symptoms such as palipitations, ventricular overload, heart failure, and pulmonary
congenstion, these symptoms may be sudden and not that frequent as they are very severe
symptoms. For symptoms such as loud mitral S1, pulmonary S2, mid-diastolic murmur,
fatigue, reduced exercise tolerance, weight gain, ankle edema, and right upper quadrant pain,
and ascities, these symptoms may be less frequent and severe; their duration may be only a
few seconds, minutes, or even months.

Major symptoms[edit]

Major symptoms of Lutembacher's syndrome as a result of ASD and MS can range from
heart failure to pulmonary congestion.

 Right ventricular overload and Right-sided heart failure: Both are caused by a large
ASD and MS (moderate to severe).
 Palpitations: This is caused by blood flowing from left atrium to the right atrium
causing a higher left atrial pressure and leading to mitral stenosis. Both atria will be
dilated (stretched or open)leading to future atrial arrhythmias or atrial fibrillation
(Riaz).
 Pulmonary congestion: When blood or fluid pools within the lungs; this is usually a
symptom of mitral stenosis and a small ASD.
 Loud mitral S1 and wide fixed split of pulmonary S2: The loud sound of the mitral S1
and the wide fixed split of pulmonary S2 is a symptoms of mitral stenosis. The sounds
often are caused by a reduced pressure gradient in the mitral area that was caused
from decompression of the left atrium from the ASD and a displacement (moving
from normal position) of the left ventricular lower portion of the heart to the a large
right ventricle. The second heart sound (S2) split is caused by the increase right heart
blood flow through the ASD causing a late closing of the pulmonary component of
the S2 as well as decreased left ventricular and aortic blood flow.
 III/IV mid diastolic murmur, early systolic murmur: This heart murmur is caused by
an increase blood flow through the tricuspid valve due to ASD; it is heard best in the
left lower sternal area or the bottom of the heart (apex).[3][7]

Minor symptoms[edit]

 Fatigue: symptoms is caused by decreased systemic (oxygenated blood to the rest of

the body)flow. When the patient suffers from MS and the blood flows from the left
atrium to the right atrium causes the forward blood flow into the left ventricle to
reduce leading to a reduction of systemic blood flow; this causes tiredness.
 Reduced exercise tolerance: symptoms also caused by decreased systemic
(oxygenated blood to the rest of the body) flow. Just as with fatigue, when the patient
suffers from MS and the blood flows from the left atrium to the right atrium, the
forward blood flow into the left ventricle is reduced leading to a reduction of systemic
blood flow; this causes tiredness and hence a reduced exercise tolerance.
 Weight gain: this is commonly found in patients with large ASD and can be a
symptom of developing right-sided heart failure. As there is a chronically increased
left-to-right blood flow through the atria, this will lead in the future to right-sided
heart failure.
 Ankle edema: This is also caused by a large ASD and has the same symptoms and
causes as seen in weight gain and right upper quadrant pain. As blood flow is not
 happening correctly and the heart is pumping under strain, pooling of blood and fluid
will happen in the ankles.
 Right upper quadrant pain: Also caused by large ASD; has same symptoms and
underlying causes as weight gain and ankle edema.
 Ascites: Ascite is known as abnormal buildup of fluid in spaces between abdomen
lining and abdominal organs. Same symptoms and causes as weight, gain, ankle
edema, and right upper quadrant pain.[7]

Less common symptoms[edit]

 Paroxysmal nocturnal dyspnea, orthopnea, and hemoptysis (sign of pulmonary venous

congestion): this symptoms are less frequent in Lutembacher's syndrome and are more
associated with MS and small ASD or patients who develop reverse Lutembacher's
syndrome. This symptom is caused by mitral stenosis.[7]

Cause-[edit]
Lutembacher is caused indirectly as the result of heart damage or disorders and not something
that is necessarily infectious. Lutembacher's syndrome is caused by either birth defects where
the heart fails to close all holes in the walls between the atria or from an episode of rheumatic
fever where damage is done to the heart valves such as the mitral valve and resultant in an
opening of heart wall between atria. With Lutembacher's syndrome, a fetus or infant is
usually seen to have a hole in their heart wall (interatrial) separating their right and left
atria.[8] Normally during fetal development, blood bypasses the lungs and is oxygenated from
the placenta. Blood passes from the umbilical cord and flows into the left atrium through an
opening called the foramen ovale; the formaen ovale is a hole between the two atria.[8] Once a
baby is born and the lungs begin to fill with air and the blood flow of the heart changes, a
tissue flap (somewhat like a trap door) called the septum primium closes the foramen ovale or
hole between the two atria and becomes part of the atrial wall. The failure of the hole
between the two atria to close after birth leads to a disorder called ASD primium.[8] The most
common problems with an opening found in the heart with Lutembacher's syndrome is
Ostium Secundum. Ostium Secundum is a hole that is found within the flap of tissue (septum
primium) that will eventually close the hole between the two atria after birth. With either type
of ASD, ASD will usually cause the blood flow from the right atrium to skip going to the
right ventricle and instead flow to the left atrium. If mitral stenosis (the hardening of flap of
tissue known as a valve which opens and closes between the left atrium and ventricle to
control blood flow) is also present, blood will flow into the right atrium through the hole
between the atria wall instead of flowing into the left ventricle and systemic circulation.[3][8]
Eventually this leads to other problems such as the right ventricle failing and a reduced blood
flow to the left ventricle.[3]

In addition to the ASD, acquired MS can be present either from an episode of rheumatic fever
(the mother has or had rheumatic fever during the pregnancy) or the child being born with the
disorder (congenital MS). With the combination of both ASD and MS, the heart can be under
severe strain as it tries to move blood throughout the heart and lungs.
Mechanism[edit]

Atrial Septal Defect (ASD)

Mitral Valve Stenosis (MS)

There is no exact mechanism for Lutembacher's syndrome but instead a combination of

disorders as the result of Atrial septal defect (ASD) and/or Mitral valve stenosis.

Lutembacher's syndrome, Atrial Septal Defect, and Mitral Valve

Stenosis[edit]

It is thought ASD is caused by the failure to close the hole (foramen ovale) between the right
and left atrium normally found within the heart during fetal development; the creation of a
hole between the atrium may also be acquired. There are two types of ASD: Ostium
secundum and ASD Primium.

Atrial Septal Defect Primium[edit]

The failure of the hole between the right and left atrium to close shortly after birth is the
cause behind ASD primium. During fetal development blood will pass from the umbilical
cord and flow into the left atrium through an hole between the two atria. Once a baby is born
and the lungs begin to fill with air, the blood flow of the heart changes; a tissue flap (septum
primium) normally closes the hole (foramen ovale) between the two atria and becomes part of
the atrial wall.[8] During ASD primium, after birth the hole is not completely closed allowing
deoxygenated blood to flow into the left atria from the right atria. With the failure of the
blood to pass from the right atrium into the right ventricle and then into the pulmonary veins,
blood will not obtain any oxygen before it is leaves the heart and goes to other parts of the
body.[8] Due to the incorrect blood flow, symptoms such as fatigue (from decreased systemic
blood flow), palpitations (from blood flowing from left atria to right atria), weight gain,
edema, right upper chest pain (all caused from the left to right atria blood flow), and
paroxysmal nocturnal dyspnea (shortness of breath during sleep), orthopnea (difficulty in
breathing while lying down), and hemoptysis or coughing up blood (all caused by small ASD
that cause blood flow from left to right atria).[7]

Atrial Septal Defect Ostium secundum[edit]

During the more common form of Lutembacher's syndrome, ASD Ostium secundum, a hole
will form in the flap of tissue (septum primium) that should close between the two atria after
birth. With the onset of a hole created in the tissue flap that closes the larger hole between the
left and right atrium, blood can again flow from the right atrium to the left.[3][8] Ostium
secundum causes many of the same symptoms seen in ASD primium. With either type of
ASD, blood will flow from the right atrium skipping the right ventricle (or very little flowing
into the ventricle) and instead flow to the left atrium introducing the possibility of blood
lacking oxygen to go the rest of the body.[3][8] Sometimes, the direction of blood flow is
largely determined by the left and right ventricle ability to squeeze (contract) and relax
(compliance).[3]

Apart from congential or birth defects causing ASD, ASD is thought to be also acquired.
During pecutaneous interventional procedures such as mitral valvuloplasty (a surgical process
done to repair a mitral valve), 11-12% of individuals will develop ASD allowing blood to
flow from the left atrium to the right.[9]

Mitral Valve Stenosis[edit]

The second cause of Lutembacher's syndrome is mitral stenosis (MS). MS can be caused by
birth defects, rheumatic fever, or just stress to the heart due to ASD; because MS can be
caused by several things, there is no exact mechanism but many mechanisms or causes. If
mitral valve stenosis is a result of birth defects during development stemming from rheumatic
fever, several things may occur in the heart. Rheumatic fever causes the immune system to
attack its own protein tissues leading to lesions forming on the mitral valve flaps. As the flaps
heals over time, the flaps lose their filmy and floppiness resulting in solid, stiff flaps. The loss
of proper flappy mitral valves makes it harder for the valves to open and allow blood to flow
through. As a result of blood flow being stopped or slowed by the faulty valve, pressure
begins to build in the heart. It was once thought an ASD is not already present, could form
because of MS, but it is now thought the ASD is either a birth defect or acquired from
surgical procedures.[9]

Overall, Lutembacher's syndrome has no certain mechanism but a combination as the result
of ASD and MS.

Diagnosis[edit]
Lutembacher's syndrome is diagnosis primarily by physical examinations for heart sounds,
electrocardiograms, chest radiogram, transthoracic or transesophageal echocardiography,
color flow mapping, and Doppler imaging. Use of the various test can help to differentiate
other possible conditions such as mitral regurgitation, Ebstein disease, ventricular septal
defect (VSD).[10]

Physical examinations[edit]

A physical examination will be done to check for abnormal heart sounds, condition of heart,
blood pressure, lungs, palpitations, edema, weight gain, ascites, or any other abnormal
symptoms. Blood may also be drawn to help determine the cause of fatigue, determination of
ascites, other health problems that maybe closely related to cause the symptoms such as
kidney, liver, immune (signs of rheumatic fever), abnormal glucose levels.

Electrocardiograms[edit]

Electrocardiogram (ECG) is used for determination of the location, size, direction of blood
flow through the atrial hole, hemodynamic of the right ventricle (blood circulation), tricuspid
valve, and functioning of left ventricle. The ECG can also be used to determine the rhythm of
the heart to determine if there is an indication of sinus rhythm or atrial fibrillation. In the
ECG, the p wave morphology will be study for any abnormalities. If during the ECG, the P-
wave (atrial depolarization)is tall, broad, or split waves in lead II and accompanied with a
deep negative force in V1, this would be considered to be abnormal; only one wave should be
associated with the P-wave. Additionally, in an ECG the QRS morphology and axis will be
examined for any abnormalities. If the ECG shows a right axis deviation which is abnormal
or a right bundle-branch block (this would mean there was no signal going through the atrium
to instruct the ventricle to contract or squeeze blood out of the ventricle).[10]

Chest radiogram[edit]

A chest radiogram can be given to a patient to determine:

 Pulmonary plethora: the test will help to determine if there is a left-to-right shunt
meaning the blood is flowing from the left atrium to the right through a hole between
the two atria.
 Mild left atrial enlargement: the test will help to determine if the left atrium is
enlarged due to alternate blood flows
 Right ventricular enlargement: the test will help to determine if the ventricle is
enlarged due to a surge of blood above normal or if the ventricle is having to work
harder than normal to pump blood out of the ventricle.
 Pulmonary artery enlargement: the test will help to determine if there is a large
volume of blood in the pulmonary veins and arteries than normal
 Mitral Valve calcification late in life: the test will help to determine if the mitral valve
or flaps are becoming hardened and losing their floppiness.
 pulmonary vascular congestion, marked left atrial enlargement: the test will help to
determine if there is a sign of MS and small ASD and how severe both are.[10]

Transthoracic or Transesophageal echocardiography[edit]

Transthoracic or Transesophageal echocardiography two dimensional images that can be

made of the heart. They can be used to determine the stages of Lutembacher's syndrome.
They are used to determine:

 Large left atrium: the test can help to determine if the left atrium is enlarged to a large
blood flow then unusually
 Large right atrium and ventricle: the test will help to determine if the right atrium and
ventricle are enlarged due to a greater blood flow
 ASD: the test will help to determine if there is a hole between the two atria and if
blood is flowing through both
 Stenotic mital valve: the test will help to determine if the blood flow through the
mitral valve is normal or if the mitral valve is stiff, has a reduced opening, and
constricting blood flow through it.[10]

Color flow mapping and Doppler imaging[edit]

A color flow and doppler imaging is used to help confirm the presence as well as evaluate the
severity of ASD and MS.[10]
Chest X-ray[edit]

A chest x-ray will be given to determine the size of the heart and the blood vessels supplying
blood to the lungs.[11]

Cardiac catheterization[edit]

Cardiac catheterization is done to confirm a diagnosis; it is not routinely done prior. It can
also be used to evaluate the severity of ASD and measure the mitral valve area. To determine
the presence ASD, a catheter is passed through the suspected hole between the atrium into the
left atrium.[6]

Treatments and prognosis[edit]

To treat Lutembacher's syndrome, the underlying causes of the disorder must first be treated:
mitral stenosis and atrial septal defect. Lutembacher's syndrome is usually treated surgically
with treatments such as:

 percutaneous transcatheter therapy for MS

 Device closure of ASD

Percutaneous transcatheter treatment for the MS can include transcatheter therapies of such as
balloon valuloplasty.

Percutaneous transcatheter therapy[edit]

Percutaneous transcatheter therapy is used to repair the mitral valve and sometimes the
septum. In percutaneous balloon mitral valvuloplasty, using a catheter, a ballon such as the
Inoue ballon is placed into blood vessels in the groin area and the balloon guided to the heart.
If a hole is not already present, a small hole may need to be inserted the atria and inserted into
the mitral valve through the left atrium; the balloon is then inflated. The balloon inside the
mitral valve will be inflated and deflated several times to wide the valve opening until the
opening is satisfactory; the balloon will then be deflated and removed.[2][12]

The advantage to using percutaneous procedures instead of open-heart surgery is not needing
general anesthesia, blood transfusions, and the recovery time is quicker. The drawback to this
procedure is the lack of repeating and transseptal procedures if they are needed later. Also if
the patient later develops a relapse of MS, surgery will need to be performed where using
more evasive techniques.[2] Additionally, if a hole is needed to be inserted into the atria to
obtain access to the mitral valve, there is a risk of developing ASD secondarily.[2]

Side effects[edit]

Possible side effects from this non-invasive procedure could be:

 fever
 Chest pain
 Shortness of breath
 Unusual swelling or weight gain
  Swelling, bleeding, change in skin color at site of initial catheterization in groin, or
pain in the groin.[12]

If any of the above symptoms occur, it is important to contact your doctor to prevent another
lapse of mitral stenosis. To ensure good health, routine doctors visits, diet, weight loss,
doctor-approved exercise, and use of antibiotics in dental and other procedures are
recommended.[12]

Device closure[edit]

To treat ASD a device closure can be used. In fact an ASD closure is often recommended for
certain cases such as with a patient who has significant left-to-right shunt with a pulmonary
and/or systemic flow fraction of Qp/Qs >1.5. It is best to perform this procedure/surgery
between the ages of 2–4 years.[6] The closure is done by two methods: interventionally or
surgically.[6]

Interventionally[edit]

This procedure is done by placing a device such as Amplatzer "umbrella", CardioSEAL

similar to percutaneous transcatheter therapy. A catheter is inserted in the vessels and
threaded to the heart and inserted into the ASD closing the defect.[6] Other closure device that
have been used is the GORE HELEX Septal Occluder.[11] After the device has been inserted
and covers the defect, over time tissue will grow over the implant device to make it become
part of the heart. Anticoagulant medication will be given to the patient for the first six months
following the surgery: aspirin, clopidogrel or warfarin (Coumadin).[11]

Surgically[edit]

This procedure is done through open heart surgery (sternotomy or thoracotomy) using an
ECC where the heart is stopped to allow a system of special cannulas to be placed. The hole
is closed by a direct suture (sewing) if the hole is small enough or if the hole is larger,
suturing (sewing) a small patch of pericardium (heart tissue or skin) or fabric to close the
hole.[6]

To increase quality life following ASD procedures/surgeries, patients should have a physical
exam and ECG every 3, 6, and 12 months with their cardiologist.[11] For many patients with
secundum ASD closure repair, they can return to their normal activities unless their
procedure was heart catheterization which in this case they should rest for a few days.[11][13]
All patients should remain on blood thinner medication for at least 6 months and up to a year
unless the patient had a stoke in which they would always be on blood thinners.[11][13] Patients
with coronary artery disease or pulmonary hypertension will take additional medicines
described by their physician. For patients who had heart surgery to repair the defect or
received a transcatheter closure device, they will need to take some form of antibiotics to
prevent infections such as endocarditis for at least 6 months following the procedure.[11][13]

Success with ASD closure is very high, 96% for percutaneous procedures and 100% of ASD
surgeries as found by one research group.[13] No patient was found to have died from either
interventional or surgical treatments and only 7.2% of patients who received a device and
24.0% of patients who had surgery had complications. The hospital stay for each group also
varied, the surgical group was 3.4 ± 1.2 days and device group 1.0 ± 0.3 days.[13] As seen by
this study, prognosis was good and quality of life could be excellent.[6]

Side effects[edit]

Side effects with interventional device closure have not been extensively supported as yet.[13]

Possible side effects from the ASD device closure procedure could be:

 fever
 Chest pain
 Swelling
 Swelling, bleeding, change in skin color at site of initial catheterization in groin, or
pain in the groin

With surgically closure, the normal risk of infection, fevers, and blood clots are among the
risks. If any signs of infection such as swelling, pain, or fever are present, the patient should
seek medical attention. Patients who have ASD repaired later in life are also at a higher risk
of developing atrial fibrillation especially if the device is not stable.[13]

Recent research[edit]
In the last five years[when?], much research has centered around the best treatment options for
patients with Lutembacher's syndrome. In a recent study of examining the benefits of using
percutaneous treatment as an alternative to surgically means to correct MS and ASD, it was
found the use of Combined percutaneous treatment was performed including balloon
valvuloplasty for MS and Amplatzer septal occluder for closure of the ASD, the patient's
planimetric mitral valve area as 2.1 cm (as compared to the previous 1.5 cm), maximum
diastolic gradient as 9 mmHg (compared to previous 17 mmHg), and mean diastolic gradient
as 4 mmHg (as compared to previous 9 mmHg).[14]

In another study, surgeons developed a way to use percanteous therapy in difficult situations.
In this study they developed a technique to use the Inoue balloon in valvuloplasty but to
insert a wire into the left atrium prior to inserting the balloon. This enabled the surgeons to be
more precise in treating the mitral valve and not have the balloon to slip out of place; the wire
served as a guide to inserting the balloon.[15]

Other Percutaneous procedures beside balloon valvuloplasty for MS have been looked into.
Percutaneous Leaflet Plication (Edge-to-Edge Leaflet Repair)is being explored as a way to
increase the opening of the mitral valve by clamping down mitral leaflets. The clamps are
delivered to the mitral through a catheter as with the balloon, and then clamped onto the
mitral valve. Of the patients that received this treatment, 74% patients achieved surgical
success, and at 1-year, 68% were saved from dying, 90% from having to have surgery or
dying from the lack thereof, a 76.3% prognosis at three years.[16]

Given the many possible treatments that are to come, future research is continuing to find
better methods of treating Lutembacher patients non-invasively as with percutaneous therapy.
Without successfully treating Lutembacher's more serious complications can occur such as
heart failure or even disorders such as Eisenmenger syndrome.[8]
[edit]
 Eisenmenger syndrome
 Ventricular Septal Defect
 Mitral regurgitation
 Ebstein disease

References[edit]
1. Jump up ^ "René Lutembacher". Whonamedit. Retrieved May 2014.
2. ^ Jump up to: a b c d e f g h Behjatiardakani, Mostafa; Mansour Rafiei; Hossein Nough;
Reza Rafiei (2011). "Trans-Catheter Therapy of Lutembacher Syndrome: A Case
Report". Acta Medica Iranica. 49 (5): 327–330.
3. ^ Jump up to: a b c d e f g h i Kulkarni, Sandhya; Amit K. Sakaria; Sanket K. Mahajan;
Kuldeep B. Shah (2012). "Lutembacher's syndrome". Journal of Cardiovascular
Disease Research. 3 (2): 179–181.
4. Jump up ^ "Facts about Atrial Septal Defect". Centers for Disease Control and
Prevention. Retrieved May 2, 2014.
5. Jump up ^ Hall, John (2011). Guyton and Hall Textbook of Medical Physiology.
Philadelphia, PA: Saunders Elsevier.
6. ^ Jump up to: a b c d e f g h Gaspar, Marian. "CHAPTER V - CARDIOVASCULAR
MALFORMATIONS (CVMs) – Marian GASPAR". Retrieved 2014-04-15.
7. ^ Jump up to: a b c d Riaz, Kamran. "Lutembacher Syndrome Clinical Presentation".
8. ^ Jump up to: a b c d e f g h i Marmur, Johnathan. "Atrial Septal Defects (ASD) and
Patent Foramen Ovale (PFO)".
9. ^ Jump up to: a b Riaz, Kamran. "Lutembacher Syndrome".
10. ^ Jump up to: a b c d e Riaz, Kamran. "Lutembacher Syndrome Workup".
11. ^ Jump up to: a b c d e f g "Atrial Septal Defect (ASD)". Cleveland Clinic. Retrieved
May 2, 2014.
12. ^ Jump up to: a b c "Diseases & Conditions". Cleveland Clinic. Retrieved May 2,
2014.
13. ^ Jump up to: a b c d e f g Krasuki, Richard (2007). "When and how to fix a 'hole in the
heart': Approach to ASD and PFO". CLEVELAND CLINIC JOURNAL OF
MEDICINE. 74 (2).
14. Jump up ^ Ozdemir, AO; Kumbasar D; Dinçer I; Atmaca Y (2010). "Percutaneous
treatment of Lutembacher syndrome: a case report". Percutaneous treatment of
Lutembacher syndrome: a case report.
15. Jump up ^ Bhambhani, Anupam; H. S. Somanath. "Percutaneous Treatment of
Lutembacher Syndrome in a Case with Difficult Mitral Valve Crossing". J INVASIVE
CARDIOL. 24 (3): E54–56.
16. Jump up ^ Chiam, Paul; Ruiz, Carlos (2011). "Percutaneous Transcatheter Mitral
Valve Repair: A Classification of the Technology". J Am Coll Cardiol Intv. 4 (1): 1–
13.

Additional references[edit]

 Goldman, Lee (2011). Goldman's Cecil Medicine (24th ed.). Philadelphia: Elsevier
Saunders. ISBN 1437727883.
External links[edit]
 00732 at CHORUS