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Yadav S, Shah S, Gajurel RM, Poudel CM, Ghimire R, Shah N. A study of Clinical Profile and in Hospital Outcomes of patients undergoing Percutaneous Transvenous Mitral Commissurotomy at a Tertiary Care Center of Nepal. Ann Med Surg (Lond) 2022; 84:104867. [PMID: 36536708 PMCID: PMC9758362 DOI: 10.1016/j.amsu.2022.104867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/26/2022] [Accepted: 10/30/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction Rheumatic heart disease (RHD), is a common cause of mitral stenosis (MS) in developing nations. As per current recommendation, Percutaneous Transvenous Mitral Commissurotomy (PTMC) is advised as a Class IA (I-Class Of Recommendation, COR; A-Level Of Evidence, LOE) indication in patients with symptomatic severe mitral stenosis. We aim to examine the clinical profile and in-hospital results of PTMC for mitral stenosis. Methods A cross-sectional retrospective study was conducted at Manmohan Cardiothoracic Vascular and Transplant Center from April 2020 to May 2022. A structured questionnaire was used to collect the data and ethical approval for conducting the study was taken from the Institutional Review Committee (IRC) of Institute of Medicine (IOM). The data was collected in Microsoft Excel (Ver. 2013). For statistical analysis, SPSS 21 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) Association was measured using a parametric and non-parametric test (depending upon the distribution of data) and p value < 0.05 was considered significant. Results A total of 104 patients who met the inclusion criteria underwent PTMC during the study period. The mean age group of the patient was 41.7 ± 12.5 years, of which 23 (22.1%) were males and 81 (78.9%) were females. Mean mitral valve area prior to PTMC was 0.98 ± 0.19 mm2 that increased to 1.69 ± 0.19 mm2 after the procedure and it was statistically significant (p=<0.001). The post PTMC MVA varied with PTMC Wilkin's score with less than or equal to 8 having favorable outcomes. Conclusion Successful PTMC is highly influenced by the patients' increasing age, valve morphology (calcification, thickness, mobility), Left atrial dimensions, Pre PTMC mitral valve area, Degree of Baseline mitral regurgitation. Post procedure development of MR is usually well tolerated but rarely be severe enough requiring surgical valve replacement.
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Key Words
- AF, atrial fibrillation
- BMV, balloon mitral valvotomy
- CMC, closed mitral commissurotomy
- LA, left atrium
- LAP, left atrial pressure
- LVEF, Left ventricular ejection fraction
- LVSD, Left ventricle systolic dysfunction
- MI, Myocardial Infarction
- MS, mitral stenosis
- MVA, mitral valve area
- MVR, mitral valve replacement
- Mitral regurgitation
- Mitral stenosis
- Mitral valve area
- NSR, normal sinus rhythm
- NYHA, New York Heart Association
- Nepal
- OMC, open mitral commissurotomy
- Outcomes
- PA, pulmonary artery
- PASP, pulmonary artery systolic pressure
- PTMC
- PTMC, percutaneous transvenous mitral commissurotomy
- RHD, rheumatic heart disease
- TTE TEE, Transthoracic Echocardiography Transesophageal Echo
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Affiliation(s)
- Sutap Yadav
- Department of Cardiology, Manmohan Cardiothoracic Vascular and Transplant Center, Maharajgunj, Nepal
| | - Sangam Shah
- Tribhuvan University, Institute of Medicine, Maharajgunj, 44600, Nepal
| | - Ratna Mani Gajurel
- Department of Cardiology, Manmohan Cardiothoracic Vascular and Transplant Center, Maharajgunj, Nepal
| | - Chandra Mani Poudel
- Department of Cardiology, Manmohan Cardiothoracic Vascular and Transplant Center, Maharajgunj, Nepal
| | - Roshan Ghimire
- Department of Cardiology, Manmohan Cardiothoracic Vascular and Transplant Center, Maharajgunj, Nepal
| | - Nischal Shah
- Department of Cardiology, Manmohan Cardiothoracic Vascular and Transplant Center, Maharajgunj, Nepal
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Sarmiento RA, Blanco R, Gigena G, Lax J, Escudero AG, Blanco F, Szarfer J, Solerno R, Tajer CD, Gagliardi JA. Initial Results and Long-Term Follow-up of Percutaneous Mitral Valvuloplasty in Patients with Pulmonary Hypertension. Heart Lung Circ 2017; 26:58-63. [DOI: 10.1016/j.hlc.2016.04.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 04/25/2016] [Accepted: 04/26/2016] [Indexed: 11/28/2022]
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Choudhary SK, Bhan A, Sharma R, Airan B, Das B, Kumar AS, Kaul U, Venugopal P. Pathology of Severe Mitral Regurgitation following Balloon Valvuloplasty. Asian Cardiovasc Thorac Ann 2016. [DOI: 10.1177/021849239700500106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study assessed the mechanism of acute mitral regurgitation following balloon mitral valvuloplasty for the treatment of symptomatic mitral stenosis. We studied 25 patients who required mitral valve replacement for severe mitral regurgitation following balloon mitral valvuloplasty. All the mitral valves studied had features of severe mitral stenosis. Radial tear of the mitral leaflet was responsible for mitral regurgitation in 18 (72%) cases. Of these, 16 involved the anterior mitral leaflet and in 2 cases the posterior mitral leaflet was torn. Three patients (12%) had chordal rupture, whereas in 4 (16%) patients pseudo-orifices were formed. All the excised mitral valves showed significant subvalvular deformity which was underestimated in prevalvuloplasty echocardiography. No other factor was found to be associated with disruption of the valve. Hence, we conclude that cusp deformity and subvalvular pathology are responsible for faulty transmission of forces and improper engagement of the balloon, resulting in disruption of the valvular apparatus. The incidence of severe mitral regurgitation following balloon mitral valvuloplasty might be decreased by appropriate prevalvuloplasty assessment and patient selection.
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Affiliation(s)
| | | | | | | | | | | | - Upendra Kaul
- Department of Cardiology Cardiothoracic Centre All India Institute of Medical Sciences New Delhi, India
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Bogunovic N, Horstkotte D, Scholtz W, Faber L, Bogunovic L, van Buuren F. A differentiated morphological parameter-coding system to describe the suitability of mitral valve stenoses intended for percutaneous valvotomy. Heart Vessels 2014; 30:632-41. [PMID: 24969674 DOI: 10.1007/s00380-014-0536-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 06/06/2014] [Indexed: 11/25/2022]
Abstract
Percutaneous balloon-mitral-valvotomy (PBMV) is an alternative to surgery in selected patients with mitral valve (MV) stenosis (MS). Applying echocardiography, suitability for PBMV is assessed by detailed morphological description. Echo-scores alone are suboptimal to describe MV morphology, because single parameters, important for a decision concerning PBMV, are not distinguishable out of a score number. The aim was to design a tool (coding-system), which combines a number for a stenotic MV like scores (for statistical options) and decodable, generally applied parameters describing the MS morphology. The reproducibility of the MS morphology using the coding-system has to be tested in 90 patients. A separate group of 297 patients (pts) with MS, scheduled for PBMV, should be investigated prospectively applying the coding-system and a comparable score. We chose the Wilkins score (WS) as representative of scores. The coding-system is designed as a parameter sequencing set consisting of 6 digits. The first digit indicates a decision code concerning suitability for PBMV. The following 5 digits indicate generally accepted morphological parameters, which are partially also used in the WS. Therefore, the MS morphology can be "read" retrospectively by decoding. 201/297 patients were found suitable for PBMV. Applying the coding-system all 201 suitable patients were correctly distinguished from 96 morphologically unsuitable patients. Astonishingly 48/96 of the rejected patients showed a WS ≤8 whereas 28/201 of the suitable patients demonstrated a WS >8. 25/28 of them showed a successful initial outcome. Applying the generally known threshold of "8" when predicting suitability of a MS, the WS demonstrated an initial success rate of 62 %, sensitivity of 0.87, specificity of 0.45, precision of 0.79, and accuracy of 0.78. Applying the coding-system, the initial success rate was 70.8 %, sensitivity = 0.96, specificity = 1.0, precision = 1.0, and accuracy = 0.97. The coding-system is an advanced diagnostic aid, is statistically applicable, offers a decodable morphological description, includes a decision code regarding suitability for PBMV, and can be used for comparing different groups of patients with MS by calculating "mean morphologies" of groups.
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Affiliation(s)
- Nikola Bogunovic
- Department of Cardiology, Heart Center North Rhine-Westphalia, Ruhr University Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Germany.
| | - Dieter Horstkotte
- Department of Cardiology, Heart Center North Rhine-Westphalia, Ruhr University Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Germany
| | - Werner Scholtz
- Department of Cardiology, Heart Center North Rhine-Westphalia, Ruhr University Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Germany
| | - Lothar Faber
- Department of Cardiology, Heart Center North Rhine-Westphalia, Ruhr University Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Germany
| | - Lukas Bogunovic
- Department of Physics, University of Bielefeld, Bielefeld, Germany
| | - Frank van Buuren
- Department of Cardiology, Heart Center North Rhine-Westphalia, Ruhr University Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Germany
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Sharma KH, Jain S, Shukla A, Bohora S, Roy B, Gandhi GD, Ashwal AJ. Patient profile and results of percutaneous transvenous mitral commissurotomy in mitral restenosis following prior percutaneous transvenous mitral commissurotomy vs surgical commissurotomy. Indian Heart J 2013; 66:164-8. [PMID: 24814109 DOI: 10.1016/j.ihj.2013.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 12/04/2013] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Patients with mitral restenosis who have undergone prior PTMC or surgical commissurotomy have increased. Predictors of outcome of repeat PTMC in either subgroup of patients may be different. AIMS AND OBJECTIVES Aim was to assess and compare the immediate results of PTMC in patients who had undergone a prior PTMC or surgical commissurotomy. METHODS AND RESULTS This is a single center, prospective, open label study. Of 70 patients in study, 44 (62.85%) patients had prior history of PTMC and 26 (37.15%) had prior surgical commissurotomy (closed/open). Average time from the initial procedure was 8.88 ± 5.36 years overall, 6.75 ± 3.38 for patients with prior PTMC and 16.73 ± 3.67 for patients with prior surgical commissurotomy. Prior PTMC group had 75% female, patients with prior surgical commissurotomy were older (44 ± 7 vs 33.57 ± 9.1 years, p = 0.001), had higher NYHA class (III/IV in100% vs 86.36%, p = 0.006.), higher atrial fibrillation (73.1% vs 25% p < 0.0001) and higher Wilkins' score (>8 in 88.46% vs 68.18%, p = 0.05). Successful PTMC was lower (65.4% vs 84.1%) in patients with prior surgical commissurotomy, though statistically not significant (p = 0.07). After PTMC, mitral valve area, PA systolic pressure, LA mean pressure and trans-mitral gradient were similar. Post procedure complications were not different in both the groups. CONCLUSION PTMC for mitral restenosis in patients with prior surgical valvotomy is as effective as in patients with prior PTMC despite older age, higher NYHA class, higher Wilkins score and atrial fibrillation and can be considered in all patients with restenosis irrespective of the type of past procedures done.
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Affiliation(s)
- Kamal H Sharma
- Associate Professor Cardiology, U. N. Mehta Institute of Cardiology and Research Centre, Asarwa, Ahmedabad, Gujarat, India
| | - Sharad Jain
- Associate Professor Cardiology, U. N. Mehta Institute of Cardiology and Research Centre, Asarwa, Ahmedabad, Gujarat, India
| | - Anand Shukla
- Associate Professor Cardiology, U. N. Mehta Institute of Cardiology and Research Centre, Asarwa, Ahmedabad, Gujarat, India
| | - Shomu Bohora
- Assistant Professor Cardiology, U. N. Mehta Institute of Cardiology and Research Centre, Asarwa, Ahmedabad, Gujarat, India
| | - Bhavesh Roy
- Assistant Professor Cardiology, U. N. Mehta Institute of Cardiology and Research Centre, Asarwa, Ahmedabad, Gujarat, India
| | - Gaurav D Gandhi
- DM Resident, Cardiology, U. N. Mehta Institute of Cardiology and Research Centre, Asarwa, Ahmedabad, Gujarat, India.
| | - A J Ashwal
- DM Resident, Cardiology, U. N. Mehta Institute of Cardiology and Research Centre, Asarwa, Ahmedabad, Gujarat, India
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Nair KKM, Pillai HS, Thajudeen A, Krishnamoorthy KM, Sivasubramonian S, Namboodiri N, Sasidharan B, Ganapathy S, Varaparambil A, Titus T, Tharakan J. Immediate and long-term results following balloon mitral valvotomy in patients with atrial fibrillation. Clin Cardiol 2012; 35:E35-9. [PMID: 23124930 DOI: 10.1002/clc.22068] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 09/28/2012] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The purpose of this study was to examine the influence of atrial fibrillation (AF) on the immediate and long-term outcome of patients undergoing balloon mitral valvotomy (BMV). HYPOTHESIS Patients with atrial fibrillation fair poorly after balloon mitral valvotomy. METHODS There were a total of 818 consecutive patients who underwent elective BMV in this institute from 1997 to 2003, with either double-lumen or triple-lumen BMV catheters included in the study. Of them, 95 were with AF. The clinical, echocardiographic, and hemodynamic data of these patients were compared with those of 723 patients in normal sinus rhythm (NSR). Immediate procedural results and long-term events were compared between the 2 study groups. RESULTS Patients with AF were older (39.9 ± 9.9 years vs 29.4 ± 10.1, P < 0.001) and presented more frequently with New York Heart Association (NYHA) class III-IV (53.7% vs 32.9%, P < 0.001), echocardiographic score >8 (47.4% vs 24.9%, P < 0.001), and with history of previous surgical commissurotomy (33.7% vs 11.5%, P < 0.001). In patients with AF, BMV resulted in inferior immediate and long-term outcomes, as reflected in a lesser post-BMV mitral valve area (1.3 ± 0.4 vs 1.6 ± 0.4 cm(2), P = 0.032) and higher event rate on follow-up. CONCLUSIONS Patients with AF were older, sicker, and had advanced rheumatic mitral valve disease. They had a higher incidence of stroke, new onset heart failure, and need for reinterventions on long-term follow-up. These patients need intense and more frequent follow-up.
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Affiliation(s)
- Krishna Kumar Mohanan Nair
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
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Bouleti C, Iung B, Laouénan C, Himbert D, Brochet E, Messika-Zeitoun D, Détaint D, Garbarz E, Cormier B, Michel PL, Mentré F, Vahanian A. Late results of percutaneous mitral commissurotomy up to 20 years: development and validation of a risk score predicting late functional results from a series of 912 patients. Circulation 2012; 125:2119-27. [PMID: 22456478 DOI: 10.1161/circulationaha.111.055905] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Long-term follow-up after percutaneous mitral commissurotomy enables predictive factors of late results to be identified. METHODS AND RESULTS Late results of percutaneous mitral commissurotomy were assessed in 1024 consecutive patients. Good immediate results, defined as valve area ≥1.5 cm(2) without mitral regurgitation >2/4, were obtained in 912 patients (89%). These 912 patients were randomly split into 2 cohorts comprising 609 and 303 patients that were used to develop and validate, respectively, a scoring system predicting late functional results. The 20-year rate of good functional results (survival without cardiovascular death, mitral surgery, or repeat percutaneous mitral commissurotomy and in New York Heart Association class I or II) was 30.2 ± 2.0%. A multivariable Cox model identified 7 predictive factors of poor late functional results: higher final mean gradient (P<0.0001), interaction between age and final mitral valve area (P<0.0001) showing that the impact of valve area decreases with age, interaction between sex and valve calcification (P<0.0001) showing that the impact of valve anatomy is stronger in men, and interaction between rhythm and New York Heart Association class showing an impact of New York Heart Association class only in patients in atrial fibrillation (P<0.0001). A 13-point score enabled 3 risk groups to be defined, corresponding to predicted good functional results of 55.1%, 29.1%, and 10.5% at 20 years in the validation cohort. CONCLUSIONS Twenty years after percutaneous mitral commissurotomy in a population of patients with varied characteristics, 30% still had good functional results. Prediction of late functional results is multifactorial and strongly determined by age and the quality of immediate results. A simple validated scoring system is useful for estimating individual patient outcome.
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Affiliation(s)
- Claire Bouleti
- Cardiology Department, AP-HP, Bichat Hospital, Paris, France
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Salarifar M, Rezvanfard M, Sadeghian H, Safir-mardanloo A, Shafii N. Mitral annular calcification predicts immediate results of percutaneous transvenous mitral commissurotomy. Cardiovasc Ultrasound 2011; 9:29. [PMID: 22035075 PMCID: PMC3217870 DOI: 10.1186/1476-7120-9-29] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Accepted: 10/28/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many previous studies have evaluated the impact of mitral valve (MV) deformity scores on the percutaneous transvenous mitral commissurotomy (PTMC) outcome in patients with mitral stenosis; however, the relationship between mitral annulus calcification (MAC) and the PTMC result has not yet been established. The current study aimed to investigate whether MAC could independently influence the immediate result of PTMC. METHODS Of all patients undergoing PTMC in our institution between April 2005 and November 2009, we included 87 patients (28.7%male, mean ± SD age = 42.8 ± 12.6 years) with rheumatic mitral stenosis who had additional data on the echocardiographic evaluation of MAC along with MV leaflets morphology. Echocardiographic assessments were repeated up to six weeks after PTMC to evaluate the immediate PTMC outcome. The frequency of the optimal PTMC result (secondary MV area > = 1.5 cm(2) with > = 25% increase and without final mitral regurgitation grade > 2) was compared between two groups of patients with MAC (n = 17) and those without MAC (n = 70). RESULTS The optimal result was obtained in 55 (63.2%) patients, whereas the result was suboptimal in 32 (36.8%) patients due to insufficient MV area increase in 31(96.9%) subjects and post-procedure mitral regurgitation grade > 2 in 1(3.1%). The rate of optimal PTMC results was less in patients with MAC in comparison to those without MAC (29.4% vs.71.4%). After adjustments for possible confounders such as age and leaflets morphological subcomponents (thickening, mobility, calcification, and subvalvular thickening), MAC remained a significant negative predictor of a suboptimal PTMC result (odds ratio = 0.154; 95%CI = 0.038-0.626, p value = 0.009) together with leaflet thickening (odds ratio = 0.214; 95%CI = 0.060-0.770, p value = 0.018). CONCLUSIONS MAC appeared to independently influence the immediate result of PTMC; therefore, mitral annulus evaluation may be considered in the echocardiographic assessment of the mitral apparatus prior to PTMC.
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Affiliation(s)
- Mojtaba Salarifar
- Interventional Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehrnaz Rezvanfard
- Research Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hakimeh Sadeghian
- Echocardiography Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Azam Safir-mardanloo
- Echocardiography Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nahid Shafii
- Research Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
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Yazıcıoğlu N, Arat Özkan A, Orta Kılıçkesmez K, Çeliker C, Mert M, Pehlivanoglu S, Enar R, Karatay C, Küçükoğlu S. Immediate and Follow-Up Results of Repeat Percutaneous Mitral Balloon Commissurotomy for Restenosis After a Succesful First Procedure. Echocardiography 2010; 27:765-9. [DOI: 10.1111/j.1540-8175.2010.01150.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Rifaie O, Ismail M, Nammas W. Immediate and long-term outcome of redo percutaneous mitral valvuloplasty: comparison with initial procedure in patients with rheumatic mitral restenosis. J Interv Cardiol 2009; 23:1-6. [PMID: 19843203 DOI: 10.1111/j.1540-8183.2009.00508.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AIMS We explored the immediate and long-term outcome of redo percutaneous mitral valvuloplasty (PMV) in a series of patients with mitral restenosis in comparison with initial PMV in the same series. METHODS We enrolled 40 consecutive patients presenting with mitral restenosis after successful initial PMV. Redo PMV was performed by the antegrade transseptal approach using either the Inoue technique or the multitrack technique. Reassessment by transthoracic echocardiography was repeated 48 hours later, and annually thereafter. Procedural success was defined as 50% or more increase of mitral valve area (MVA) with a final MVA >or=1.5 cm(2), without major complications. Restenosis was defined as loss of >50% of the initial gain of MVA by the preceding PMV with a final MVA <1.5 cm(2). RESULTS Procedural success was achieved in 37 (92.5%) patients. Both the initial and redo procedures were similar concerning the final MVA and mean transmitral pressure gradient (P > 0.05 for all). The gain of MVA was higher in the initial as compared to the redo procedure (P < 0.001). The initial mitral valve score correlated negatively with the final MVA in both the initial and redo procedures, and was the only independent predictor of the time to redo procedure, by multivariate regression analysis. At long-term follow-up (61 +/- 2.8 months), the mean MVA was 1.6 +/- 0.3 cm(2). Three patients--out of 12 available for follow-up--developed restenosis. CONCLUSION Redo PMV for mitral restenosis is feasible, safe, and achieves immediate and long-term outcome comparable to initial PMV.
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Affiliation(s)
- Osama Rifaie
- Department of Cardiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Predicting success and long-term outcomes of percutaneous mitral valvuloplasty: a multifactorial score. Am J Med 2009; 122:581.e11-9. [PMID: 19486721 DOI: 10.1016/j.amjmed.2008.10.038] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2008] [Revised: 09/23/2008] [Accepted: 10/31/2008] [Indexed: 11/20/2022]
Abstract
BACKGROUND Percutaneous mitral valvuloplasty (PMV) success depends on appropriate patient selection. A multifactorial score derived from clinical, anatomic/echocardiographic, and hemodynamic variables would predict procedural success and clinical outcome. METHODS Demographic data, echocardiographic parameters (including echocardiographic score), and procedure-related variables were recorded in 1085 consecutive PMVs. Long-term clinical follow-up (death, mitral valve replacement, redo PMV) was performed. Multivariate regression analysis of the first 800 procedures was performed to identify independent predictors of procedural success. Significant variables were formulated into a risk score and validated prospectively. RESULTS Six independent predictors of PMV success were identified: age less than 55 years, New York Heart Association classes I and II, pre-PMV mitral area of 1 cm(2) or greater, pre-PMV mitral regurgitation grade less than 2, echocardiographic score of 8 or greater, and male sex. A score was constructed from the arithmetic sum of variables present per patient. Procedural success rates increased incrementally with increasing score (0% for 0/6, 39.7% for 1/6, 54.4% for 2/6, 77.3% for 3/6, 85.7% for 4/6, 95% for 5/6, and 100% for 6/6; P < .001). In a validation cohort (n = 285 procedures), the multifactorial score remained a significant predictor of PMV success (P < .001). Comparison between the new score and the echocardiographic score confirmed that the new index was more sensitive and specific (P < .001). This new score also predicts long-term outcomes (P < .001). CONCLUSION Clinical, anatomic, and hemodynamic variables predict PMV success and clinical outcome and may be formulated in a scoring system that would help to identify the best candidates for PMV.
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Song JK, Song JM, Kang DH, Yun SC, Park DW, Lee SW, Kim YH, Lee CW, Hong MK, Kim JJ, Park SW, Park SJ. Restenosis and adverse clinical events after successful percutaneous mitral valvuloplasty: immediate post-procedural mitral valve area as an important prognosticator. Eur Heart J 2009; 30:1254-62. [PMID: 19346230 DOI: 10.1093/eurheartj/ehp096] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AIMS We sought to investigate the factors associated with restenosis and its potential association with late clinical deterioration after successful percutaneous mitral valvuloplasty (PMV). METHODS AND RESULTS We analysed echocardiographic (median 74 months) and clinical (median 109 months) follow-up data of 329 patients who achieved procedural success, defined as mitral valve area (MVA) > or =1.5 cm(2) and mitral regurgitation (MR) < or =2/4, between 1995 and 2000. Clinical events included cardiovascular death, mitral valve surgery, and repeat PMV. The 1, 3, 5, 7, and 9 year rates of restenosis-free survival were 99 +/- 1%, 97 +/- 1%, 95 +/- 1%, 86 +/- 3%, and 72 +/- 4%, respectively. The 1, 3, 5, 7, and 9 year rates of event-free survival were 99.7 +/- 0.3%, 96.4 +/- 1.0%, 94.5 +/- 1.3%, 90.8 +/- 1.6%, and 90.0 +/- 1.7%, respectively. Immediate post-PMV MVA and commissural MR or splitting, indicators of procedural adequacy, were independent predictors of both restenosis and clinical events. The best immediate post-PMV MVA cut-off value for predicting both restenosis and clinical events within 5 years after successful PMV were 1.8 cm(2) [95% confidence interval (CI) = 1.7-1.9] and 1.9 cm(2) (95% CI = 1.7-2.0), respectively. Patients with immediate post-PMV MVA <1.8 cm(2) showed significantly lower event-free survival rate than those with post-PMV MVA > or =1.8 cm(2) (P < 0.001). CONCLUSION Immediate post-PMV MVA> or =1.8 cm(2) was an important predictor of both restenosis- and clinical event-free survival and this value should be considered as a component of optimal result.
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Affiliation(s)
- Jae-Kwan Song
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Poongnap-dong Songpa-ku, Seoul 138-736, South Korea.
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Tarka EA, Blitz LR, Herrmann HC. Hemodynamic effects and long-term outcome of percutaneous balloon valvuloplasty in patients with mitral stenosis and atrial fibrillation. Clin Cardiol 2009; 23:673-7. [PMID: 11016017 PMCID: PMC6654854 DOI: 10.1002/clc.4960230908] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The presence of atrial fibrillation (AF) has been identified as a predictor of a suboptimal result in some patients undergoing percutaneous balloon valvuloplasty in the treatment of symptomatic rheumatic mitral stenosis. HYPOTHESIS Atrial fibrillation adversely affects the short- and long-term outcome of patients with mitral stenosis undergoing percutaneous balloon valvuloplasty. METHODS A retrospective chart review of 104 consecutive patients with rheumatic mitral stenosis undergoing percutaneous balloon valvuloplasty was performed. A successful procedure was defined as a final mitral valve area > or = 1.5 cm2 and the absence of a complication. Endpoints included freedom from mitral valve replacement, death, and repeat balloon valvuloplasty at 5 years. RESULTS A successful procedure was obtained in 89% of patients with sinus rhythm and in 78% of patients with AF (p = NS). Patients in sinus rhythm had a greater cardiac output resulting in a larger final valve area than patients in AF (1.8 vs. 1.6 cm2, p < 0.05). Freedom from valve replacement, death, and repeat balloon valvuloplasty at 5 years was 75% for patients in AF and 76% for patients in sinus rhythm (p = NS). Lower postprocedure mitral regurgitation grade and absence of prior commissurotomy were the only independent predictors of event-free survival. CONCLUSIONS Patients with mitral stenosis and AF have lower cardiac outputs and gradients than patients with sinus rhythm, despite similar valve areas. The long-term outcome of balloon valvuloplasty is independent of the initial cardiac rhythm.
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Affiliation(s)
- E A Tarka
- Department of Medicine, University of Pennsylvania Medical Center, Philadelphia 19104, USA
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14
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Rifaie O, Abdel-Dayem MK, Ramzy A, Ezz-El-din H, El-Ziady G, El-Itriby A, El-Sayed H, Wagdy H, Awadallah H, Nammas W. Percutaneous mitral valvotomy versus closed surgical commissurotomy. Up to 15 years of follow-up of a prospective randomized study. J Cardiol 2009; 53:28-34. [DOI: 10.1016/j.jjcc.2008.08.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2008] [Revised: 07/31/2008] [Accepted: 08/08/2008] [Indexed: 11/28/2022]
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15
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Marcus GM, Ren X, Tseng ZH, Badhwar N, Lee BK, Lee RJ, Foster E, Olgin JE. Repeat Transseptal Catheterization After Ablation for Atrial Fibrillation. J Cardiovasc Electrophysiol 2007; 18:55-9. [PMID: 17081207 DOI: 10.1111/j.1540-8167.2006.00657.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION A substantial number of patients require a second left atrial procedure after ablation for atrial fibrillation (AF), either for left atrial flutter or recurrent AF. The success and complication rates of repeat transseptal catheterization in these patients are unknown. The aim of this study was to determine the difficulty and/or success rates of repeat transseptal catheterization after left atrial ablation for AF. METHODS AND RESULTS Consecutive patients undergoing repeat left atrial procedures after ablation for AF over a 1-year period were enrolled. Difficulties with, success rates, and complications of the first and second transseptal catheterizations were recorded. Sixteen patients underwent a repeat transseptal catheterization. Of the 4 in whom the first procedure was performed with an ablation catheter across a patent foramen ovale (PFO), 3 required a transseptal puncture for their repeat procedure. The remaining 12 underwent transseptal puncture without difficulty for their first procedure, and, despite the same operators for each patient, the repeat transseptal was noted to be difficult in 5. Of those 5, the transseptal puncture was unsuccessful due to increased interatrial septal thickness in 2 patients. One repeat transseptal attempt was aborted after posterior right atrial puncture with the transseptal needle occurred, attributed to distorted interatrial septal anatomy not observed prior to the first case. CONCLUSIONS Compared with the first procedure, repeat transseptal catheterization after ablation for AF, whether initially performed across a PFO or via a transseptal puncture, is more difficult, less often successful, and potentially associated with more complications.
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Affiliation(s)
- Gregory M Marcus
- Division of Cardiology, Electrophysiology Section, University of California, San Francisco, California 94143-1354, USA.
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16
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Ramondo A, Napodano M, Fraccaro C, Razzolini R, Tarantini G, Iliceto S. Relation of patient age to outcome of percutaneous mitral valvuloplasty. Am J Cardiol 2006; 98:1493-500. [PMID: 17126657 DOI: 10.1016/j.amjcard.2006.07.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2006] [Revised: 07/03/2006] [Accepted: 07/03/2006] [Indexed: 11/24/2022]
Abstract
The aim of this study was to evaluate the impact of age on immediate- and long-term outcomes of percutaneous mitral balloon valvuloplasty (PMV). PMV is the first-line treatment for patients with symptomatic mitral stenosis. However, long-term results in large series of patients from Europe and the United States have been found less favorable than those from Asia and South America involving younger patients. Six hundred ten patients who underwent 626 PMV procedures were prospectively followed for 6.1 +/- 4.10 years using clinical and echocardiographic evaluation. Patients were divided in quartiles according to age: < or =41 years (n = 163), 42 to 53 years (n = 163), 54 to 63 years (n = 142), and >63 years (n = 158). The success of PMV was defined as valve area > or =1.5 cm(2) without severe regurgitation; restenosis was defined as a loss > or =50% of initial gain, with a valve area of <1.5 cm(2). PMV success was significantly more prevalent in younger patients: 95.7% in group 1, 91.4% in group 2, 86.4% in group 3, and 83.4% in group 4 (p = 0.002). No significant differences in complications were found among all age groups, including death, cardiac tamponade, emergency mitral replacement, and any embolic events (p = NS). Event-free survival was greater in younger patients (p <0.0001), but on multivariate analysis, age was not an independent predictor of events (p = NS). Restenosis occurred in 27.9% of patients, throughout all groups (p = NS). In conclusion, PMV may be safely and effectively performed in younger and older patients. Although event-free survival was greater in younger groups, multivariate analysis did not find that age was an independent predictor of events.
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Affiliation(s)
- Angelo Ramondo
- Department of Cardiac Thoracic and Vascular Sciences, University of Padova, Padova, Italy
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17
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Yilmaz MB, Demirkan B, Caldir V, Guray Y, Guray U, Sasmaz H, Korkmaz S. Association of lipid profile with echocardiographic Wilkins score in patients with moderate to severe mitral stenosis: possible impact on prognosis. Int J Cardiol 2006; 112:329-33. [PMID: 16290100 DOI: 10.1016/j.ijcard.2005.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2005] [Revised: 07/25/2005] [Accepted: 10/02/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Association of valvular heart disease and lipid profile might be important as in the case of aortic stenosis. However, it has not been so far considered in detail the probable association of other valvular diseases, particularly of mitral stenosis (MS) with lipid profile. In our study, we aimed to search possible association of echocardiographic mitral valve score, evaluated according to Wilkins score, with lipid parameters in a group of patients with mitral stenosis, who were referred for possible percutaneous balloon valvuloplasty. MATERIAL AND METHOD We retrospectively reviewed 401 patients (316 female, 85 male), who were referred as possible candidates for PMBV, with moderate to severe MS of predominantly rheumatic origin. Mitral valve was evaluated according to Wilkins score by an experienced author as indicated. RESULTS Mean age of all patients was 36.6+/-11.3 years, and was not different in both genders. Mean mitral valve area was 1+/-0.1 mm2. Considering all patients, total Wilkins score was significantly, but mildly correlated with ratio of total/HDL cholesterol ratio (r=0.174, p=0.02). Presence of more than one recurrent attack of rheumatic fever, narrow mitral valve area, high total/HDL cholesterol and being male were independent predictors of poor echocardiographic Wilkins score (>8). CONCLUSION We think that Wilkins echocardiographic score of mitral stenosis, particularly of leaflet thickening, might well be associated with serum lipids, probably as the same extent does aortic stenosis.
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Affiliation(s)
- Mehmet Birhan Yilmaz
- Yuksek Ihtisas Education and Research Hospital, Cardiology Clinic, Sihhiye, Ankara, Turkey.
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18
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Abstract
Recent innovations have occurred in the treatment of valvular heart disease so that we now stand at the very beginning of a field that is likely to show considerable growth in the future. These innovations include the introduction of self-expanding and balloon-expandable stents containing bioprosthetic heart valves, and other valvular implants and techniques for the repair and treatment of valvular heart disease. Previously, the field of nonsurgical cardiac valve repair and replacement consisted solely of the use of balloon valvuloplasty for valvular stenosis. The ability to address aortic stenosis more definitively than with balloon valvuloplasty and to address regurgitant valve lesions will greatly expand the patients who can be treated without surgery. Percutaneous valve repair and replacement is at an early stage with a variety of techniques that are undergoing investigation. Similar to the initial development of balloon angioplasty for coronary artery disease, improvements in technology, techniques, and experience will be necessary before we can reproduce the excellent results achieved today with surgery.
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Affiliation(s)
- Howard C Herrmann
- Hospital of the University of Pennsylvania, 3400 Spruce Street, 9 Founders Pavilion, Philadelphia, PA 19104, USA.
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19
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Fawzy ME, Hassan W, Shoukri M, Al Sanei A, Hamadanchi A, El Dali A, Al Amri M. Immediate and long-term results of mitral balloon valvotomy for restenosis following previous surgical or balloon mitral commissurotomy. Am J Cardiol 2005; 96:971-5. [PMID: 16188526 DOI: 10.1016/j.amjcard.2005.05.055] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2005] [Revised: 05/16/2005] [Accepted: 05/16/2005] [Indexed: 11/27/2022]
Abstract
This study compared immediate with long-term results of mitral balloon valvotomy (MBV) in patients who underwent MBV as an initial procedure versus those who underwent repeat MBV. Fifty-six patients who were a mean age of 28 +/- 8.8 years (group A) and had mitral restenosis after surgical or balloon commissurotomy underwent MBV and were compared with 524 patients who were a mean age of 31 +/- 11 years (group B) and underwent MBV as an initial procedure. Prospective data obtained included demographic, hemodynamic, echocardiographic, and clinical follow-up for 0.5 to 15 years after MBV. No deaths or technical failure were encountered after MBV. Mitral regurgitation >2/4 occurred in 1 patient (2%) in group A and in 9 patients (2%) in group B (p = 0.24). Fifty-two of 56 patients (93%) in group A had good immediate results (mitral valve area >or=1.5 cm(2), mitral regurgitation <2/4), as did 504 of 524 patients (96%) in group B (p = 0.4). Actuarial values for freedom from restenosis at 10 years were 58 +/- 7% for group A versus 69 +/- 3% for group B (p = 0.18). Ten-year event-free survival rate was 54 +/- 7% for group A versus 80 +/- 3% for group B (p <0.005). The predictors of event-free survival were age (p = 0.003), echocardiographic score (p <0.0001), and baseline atrial fibrillation (p = 0.01). In conclusion, MBV is safe and provides good immediate results in patients who have restenosis. Long-term results are inferior compared with de novo mitral stenosis but is still satisfactory. More than 50% of patients remained improved at 10 years, thus enabling the operation or reoperation to be deferred.
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Affiliation(s)
- Mohamed Eid Fawzy
- The King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
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20
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Fawzy ME, Stefadouros MA, Hegazy H, Shaer FE, Chaudhary MA, Fadley FA. Long term clinical and echocardiographic results of mitral balloon valvotomy in children and adolescents. Heart 2005; 91:743-8. [PMID: 15894766 PMCID: PMC1768960 DOI: 10.1136/hrt.2004.040766] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
AIMS To assess the safety, efficacy, and long term results of mitral balloon valvotomy (MBV) for rheumatic mitral stenosis in children and adolescents in comparison to adults. METHODS The results of 468 patients with mitral stenosis who underwent successful MBV and were followed up for 0.5-13 years were analysed. Patients were divided according to age at the time of MBV into group 1 consisting of 84 patients < or = 20 years of age (children and adolescents) and group 2 that included 384 patients, age > 20 (adults). RESULTS Patients in group 1 had a lower mitral echo score (mean (SD) 7.5 (1.3) v 8 (1.1), p < 0.001), smaller Doppler mitral valve area (MVA) (0.84 (0.17) v 0.92 (0.18) cm2, p < 0.001), and higher Doppler mitral valve gradient (15.0 (5.3) v 12.7 (4.5) mm Hg, p < 0.001) than group 2. Immediately after MBV group 1 had larger MVA, whether measured by Doppler (2.0 (0.30) v 1.96 (0.28) cm2, p < 0.05) or by catheter (2.0 (0.59) v 1.8 (0.52) cm2, p < 0.001), and similar complication rates, compared to group 2. After a mean follow up of 5 (3.5) years there was no significant difference between groups 1 and 2 in the incidence of restenosis (14.3% v 16.1%, NS). Event-free survival rates at 5, 10, and 12.5 years were 93%, 79%, and 79% for group 1 and 94%, 90%, and 84% for group 2 (p = 0.18). CONCLUSIONS MBV is safe and effective in children and adolescents with rheumatic mitral stenosis. It provides better immediate results than in adults and excellent long term results that are comparable to those seen in adults.
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Affiliation(s)
- M E Fawzy
- Department of Cardiovascular Diseases and the Department of Biostatistics, Epidemiology, King Faisal Specialist Hospital and Research Center Riyadh, Saudi Arabia.
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21
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Guérios EE, Bueno RRL, Nercolini DC, Tarastchuk JCE, Andrade PMP, Pacheco ALA, Perreto S. Randomized comparison between Inoue balloon and metallic commissurotome in the treatment of rheumatic mitral stenosis: immediate results and 6-month and 3-year follow-up. Catheter Cardiovasc Interv 2005; 64:301-11. [PMID: 15736262 DOI: 10.1002/ccd.20262] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The metallic commissurotome (MC) technique is a cheaper alternative to the Inoue balloon (IB) technique for percutaneous mitral valvuloplasty (PMV). There are no randomized trials comparing these techniques with longer follow-up of the patients. The objective of this study was to compare the immediate results and short- and medium-term follow-up of PMV using either the IB or the MC technique. Fifty patients with rheumatic mitral stenosis were randomly assigned to PMV using the IB (n = 27) or the MC (n = 23) technique. There were no significant differences between the groups regarding baseline clinical, echocardiographic, and hemodynamic data. Clinical and echocardiographic follow-up were done 6 months and 3 years after the procedure. The success rate was 100% in the IB group and 91.3% in the MC group (P = 0.15); two patients in the latter group developed mitral regurgitation grade 3/4, requiring elective surgery. The mean final mitral valve area was bigger in the MC group (2.17 +/- 0.13 vs. 2.00 +/- 0.36 cm2; P = 0.04), but after 6-month and 3-year follow-up, this difference was no longer significant (2.06 +/- 0.27 vs. 1.98 +/- 0.38 cm2, P = 0.22, and 1.86 +/- 0.32 vs. 1.87 +/- 0.34 cm2, P = 0.89, respectively). This finding suggests valve stretching as an important mechanism of valve dilation with the MC. Three patients in the MC group and two patients in the IB group (P = 0.65) developed mitral valve restenosis; one of them underwent repeat PMV and the other four, all asymptomatic, were clinically followed. PMV performed either with the IB or the MC technique is effective and provides excellent short- and medium-term outcomes regardless of the technique employed.
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Affiliation(s)
- Enio E Guérios
- Interventional Cardiology Department, Hospital Universitário Evangélico, Curitiba, Brazil.
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22
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Routray SN, Mishra TK, Swain S, Patnaik UK, Behera M. Balloon mitral valvuloplasty during pregnancy. Int J Gynaecol Obstet 2004; 85:18-23. [PMID: 15050462 DOI: 10.1016/j.ijgo.2003.09.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2003] [Revised: 09/17/2003] [Accepted: 09/24/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Balloon mitral valvuloplasty (BMV) has been performed safely during pregnancy with good results. Reports are few on long-term effects of BMV on childhood development. METHODS BMV was performed in 40 pregnant women (age 23.4+/-4.8 years) with severe mitral stenosis at 24.2+/-4.6 weeks of gestation. RESULTS Mitral valve area increased from 0.82+/-0.34 to 1.9+/-0.4 cm(2) (P<0.001). One patient had pericardial tamponade. Mean fluoroscopy time was 5.5+/-3.8 min. There was no maternal death, no abortion, no intrauterine growth restriction and one stillbirth. All 39 babies were normal at birth. One baby died at 7 months due to pneumonia. On follow up for 36+/-15 months, all 38 babies maintained normal growth and development without any thyroid disease or malignancy. CONCLUSIONS During pregnancy BMV is feasible, safe and effective. Maternal and fetal outcomes are excellent. Growth and milestone of development are not affected.
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Affiliation(s)
- S N Routray
- Department of Cardiology, SCB Medical College, Cuttack, Orissa, India.
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23
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Abstract
The decrease in the incidence of acute rheumatic fever in western countries has led to a sharp decrease in the incidence of mitral stenosis. This decrease also modifies the clinical presentation and mitral stenosis is now encountered in older patients who have severe impairment of valve anatomy. In developing countries, mitral stenosis remains a frequent disease. The management of patients with mitral stenosis has been modified by the development of percutaneous mitral commissurotomy whose safety and efficacy have been demonstrated in a number of studies with a follow-up of up to ten years. Percutaneous mitral commissurotomy is now the reference treatment for mitral stenosis with pliable valves in young patients and its efficacy has been validated in randomised trials versus surgery. Mitral stenosis in older patients, as it is encountered in western countries, is a more heterogeneous group. Predictive analysis has shown that the predictions of immediate and late results are multifactorial. This has led to consider the indications for percutaneous mitral commissurotomy in patients who do not have ideal anatomic conditions, when their other characteristics are favourable. This is particularly the case in young patients who do not have a very tight mitral stenosis (1-1.5 cm2) and who do not have an advanced heart disease. When the conditions are favourable, percutaneous mitral commissurotomy can be considered in patients who have few symptoms, in particular in order to reduce the thromboembolic risk.
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Affiliation(s)
- B Iung
- Service de cardiologie, hôpital Bichat, 46, rue Henri-Huchard, 75877 Paris, France.
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24
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Palacios IF, Sanchez PL, Harrell LC, Weyman AE, Block PC. Which patients benefit from percutaneous mitral balloon valvuloplasty? Prevalvuloplasty and postvalvuloplasty variables that predict long-term outcome. Circulation 2002; 105:1465-71. [PMID: 11914256 DOI: 10.1161/01.cir.0000012143.27196.f4] [Citation(s) in RCA: 182] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Percutaneous mitral balloon valvuloplasty (PMV) results in good immediate results, particularly in patients with echocardiographic scores (Echo-Sc) < or =8. However, which variables relate to long-term outcome is unclear. METHODS AND RESULTS We report the immediate and long-term clinical follow-up (mean, 4.2+/-3.7 years; range, 0.5 to 15) of 879 patients who underwent 939 PMV procedures. Patients were divided into 2 groups, Echo-Sc < or =8 (n=601) and Echo-Sc >8 (n=278). PMV resulted in an increase in mitral valve area from 1.0+/-0.3 to 2.0+/-0.6 cm2 in patients with Echo-Sc < or =8 and from 0.8+/-0.3 to 1.6+/-0.6 cm2 in patients with Echo-Sc >8 (P<0.0001). Although adverse events (death, mitral valve surgery, and redo PMV) were low within the first 5 years of follow-up, a progressive number of events occurred beyond this period. Nevertheless, survival (82% versus 57%) and event-free survival (38% versus 22%) at 12-year follow-up was greater in patients with Echo-Sc < or =8 (P<0.0001). Cox regression analysis identified post-PMV mitral regurgitation > or =3+, Echo-Sc >8, age, prior surgical commissurotomy, NYHA functional class IV, pre-PMV mitral regurgitation > or =2+, and higher post-PMV pulmonary artery pressure as independent predictors of combined events at long-term follow-up. CONCLUSIONS The immediate and long-term outcome of patients undergoing PMV is multifactorial. The use of the Echo-Sc in conjunction with other clinical and morphological predictors of PMV outcome allows identification of patients who will obtain the best outcome from PMV.
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Affiliation(s)
- Igor F Palacios
- Cardiac Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass 02114, USA.
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25
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Abstract
Percutaneous mitral commissurotomy (PMC) is the treatment of choice in young patients who have favorable valve anatomy. It affords an event-free survival greater than 90% at 5 to 7 years,. Economic considerations are the main limitation of PMC in such patients, who are mainly encountered in developing countries. Mitral stenosis in older patients with less favorable valve anatomy is the most frequent presentation in Western countries. This represents a heterogeneous group, but predictive analyses are helpful in deciding who should have PMC. The main conclusion is that the prediction of immediate and late results is multifactorial. Good results can be expected in young patients with unfavorable valve anatomy who do not have a very tight stenosis, are moderately symptomatic, and in sinus rhythm. In addition, PMC may reduce the thromboembolic risk related to mitral stenosis.
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Affiliation(s)
- Bernard Iung
- Cardiology Department, Bichat Hospital, 46 rue Henri Huchard, 75877 Paris Cedex 18, France.
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Wang A, Krasuski RA, Warner JJ, Pieper K, Kisslo KB, Bashore TM, Harrison JK. Serial echocardiographic evaluation of restenosis after successful percutaneous mitral commissurotomy. J Am Coll Cardiol 2002; 39:328-34. [PMID: 11788227 DOI: 10.1016/s0735-1097(01)01726-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES This study was designed to determine predictors of restenosis after successful percutaneous mitral commissurotomy (PMC) and its relationship to late clinical outcome. BACKGROUND The restenosis rate after PMC and its relationship to late clinical outcome is poorly defined. METHODS Serial echocardiography was performed in 310 patients who underwent PMC. Restenosis, defined as mitral valve area (MVA) <1.5 cm(2) and > or = 50% loss of initial MVA increase, was determined by both two-dimensional (2D) and Doppler echocardiography. Clinical, echocardiographic and cardiac catheterization variables were evaluated to determine predictors of restenosis. The relationship between restenosis and major adverse clinical events (death, repeat PMC or mitral valve replacement) and functional status was assessed. RESULTS Acute procedural success occurred in 206 patients (66%), who were then followed for restenosis. The cumulative restenosis rate was approximately 40% at six years after successful PMC (44% by 2D and 40% by Doppler MVA). The only independent predictor of restenosis was echocardiographic score (restenosis at five years was 20% for score <8 vs. 61% for score > or = 8, p < 0.001). The decline in MVA and occurrence of restenosis was gradual and progressive during the follow-up period. Procedural results and baseline factors predicted event-free survival. Restenosis by 2D MVA was related to adverse events or New York Heart Association functional class 3 to 4 symptoms, but restenosis was not an independent predictor of clinical outcome by multivariate analysis. CONCLUSIONS Restenosis is a common, gradual and progressive occurrence after successful PMC and is predicted by higher echocardiographic score. Restenosis is related to late adverse clinical outcome, though clinical outcome remains best predicted by the acute procedural results of PMC.
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Affiliation(s)
- Andrew Wang
- Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA.
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27
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Ben-Farhat M, Betbout F, Gamra H, Maatouk F, Ben-Hamda K, Abdellaoui M, Hammami S, Jarrar M, Addad F, Dridi Z. Predictors of long-term event-free survival and of freedom from restenosis after percutaneous balloon mitral commissurotomy. Am Heart J 2001; 142:1072-9. [PMID: 11717614 DOI: 10.1067/mhj.2001.118470] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Most long-term studies after balloon mitral commissurotomy (BMC) were from industrialized countries. Less is known about the long-term results of BMC from developing countries where patients are younger with fewer mitral valve deformities. METHODS Between December 1987 and December 1998, we performed BMC in 654 patients whose mean age was 33 +/- 13 years. Baseline and postprocedural variables were evaluated to identify predictors of event-free survival (survival without repeat BMC or mitral valve replacement) and of freedom from restenosis defined as a mitral valve area (MVA) >/=1.5 cm(2) after BMC and <1.5 cm(2) at follow-up. RESULTS The actuarial survival rates were 98%, 98%, and 97% at 5, 7, and 10 years, respectively. The 5-, 7-, and 10-year event-free survival rates were 85%, 81%, and 72%. Multivariate predictors of a higher 10-year event-free survival rate were lower echocardiographic score (79% for a score </=8, 61% for a score of 9 to 11, 62% for a score >/=12, P <.001) and cardiac sinus rhythm (P =.04) before BMC, lower mean left atrial pressure (P <.001), lower mitral valve gradient (P <.001), and less than or equal to grade 2 mitral regurgitation (P =.036) after BMC. Restenosis occurred in 16% of patients. The restenosis-free rates were 88%, 80%, and 66% at 5, 7, and 10 years, respectively. A higher freedom from restenosis at 10 years was associated with a lower score (77% for a score </=8, 45% for a score of 9-11 and 50% for a score >/=12, P =.03) and a larger MVA before BMC (P =.03), a larger MVA (P <.001), and a lower mitral valve gradient (P =.04) after BMC. CONCLUSIONS BMC produces excellent 10-year results in patients with pliable mitral stenosis and good results in patients with semipliable or calcified mitral stenosis. BMC is the procedure of choice in patients with pliable valves and it is a reasonable treatment option in young patients with unfavorable mitral valve anatomy.
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Affiliation(s)
- M Ben-Farhat
- Division of Cardiology, Fattouma Bourguiba University Hospital, Monastir, Tunisia.
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Sanchez PL, Harrell LC, Salas RE, Palacios IF. Learning curve of the Inoue technique of percutaneous mitral balloon valvuloplasty. Am J Cardiol 2001; 88:662-7. [PMID: 11564391 DOI: 10.1016/s0002-9149(01)01810-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
There is controversy as to whether the double-balloon or the Inoue technique of percutaneous mitral balloon valvuloplasty (PMBV) provides superior immediate and long-term results. This study was undertaken to analyze the effect of the learning curve of the Inoue technique of PMBV in the immediate and long-term outcome of PMBV. The learning curve of Inoue PMBV was analyzed in 233 Inoue PMBVs divided into 2 groups: "early experience" (n = 100) and "late experience" (n = 133). The results of the overall Inoue technique were compared with those of 659 PMBVs performed with the double-balloon technique. Baseline clinical and morphologic characteristics between early and late experience Inoue groups were similar. Post-PMBV mitral valve area (1.89 +/- 0.56 vs 1.69 +/- 0.57 cm(2); p = 0.008) and success rate (60% vs 75.9%; p = 0.009) were significantly higher in the late experience Inoue group. Furthermore, there was a trend for less incidence of severe post-PMBV mitral regurgitation > or = 3+ in the late experience group (6.8% vs 12%; p = 0.16). Although the post-PMBV mitral valve area was larger with the double-balloon technique (1.94 +/- 0.72 vs 1.81 +/- 0.58 cm(2); p = 0.01), the success rate (71.3% vs 69.1%; p = NS), incidence of > or = 3+ mitral regurgitation (9% vs 9%), in-hospital complications, and long-term and event-free survival were similar with both techniques. In conclusion, there is a significant learning curve of the Inoue technique of PMBV. Both the Inoue and the double-balloon techniques are equally effective techniques of PMBV because they resulted in similar immediate success, in-hospital adverse events, and long-term and event-free survival.
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Affiliation(s)
- P L Sanchez
- Cardiac Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA
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Sutaria N, Northridge DB, Shaw TR. Significance of commissural calcification on outcome of mitral balloon valvotomy. Heart 2000; 84:398-402. [PMID: 10995409 PMCID: PMC1729439 DOI: 10.1136/heart.84.4.398] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the significance of commissural calcification, identified by transthoracic echocardiography, on the haemodynamic and symptomatic outcome of mitral balloon valvotomy. METHODS Commissural calcification was graded from 0-4 using parasternal short axis transthoracic views. The morphology of the mitral valve was also assessed using the Massachusetts General Hospital echo score. SETTING A tertiary cardiac centre in Scotland. PATIENTS 300 patients were studied, 85 retrospectively and 215 prospectively. Mean (SD) age was 59.8 (12.7) years, range 13 to 87; 30% had been judged unsuitable for surgery. Median echo score was 6.8 (3.0), range 2-16. MAIN OUTCOME MEASURES Immediate increase in mitral valve area and in New York Heart Association functional class 1-3 months after balloon valvotomy. RESULTS On univariate and multivariate analysis, commissural calcification grade was a significant predictor of achieving a mitral valve area of > 1.50 cm(2) without severe mitral reflux. Its influence was greatest in patients with an echo score </= 8: those with commissural calcification grade 0/1 had significantly greater improvement in valve area and symptom status than those with grade 2/3; the proportions of patients achieving a final valve area of > 1.50 cm(2) were 67% and 46%, respectively (p < 0.05). In patients with an echo score of > 8, the influence of commissural calcification was smaller and not significant. CONCLUSIONS Commissural calcification as assessed by transthoracic echocardiography is a useful predictor of outcome in patients with otherwise "good" valves (echo score </= 8). Calcification of one commissure or more predicts a less than 50% probability of achieving a valve area above 1.50 cm(2) and is an indication for valve replacement in those who are suitable for surgery.
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Affiliation(s)
- N Sutaria
- Department of Cardiology, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK
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30
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Iung B, Garbarz E, Doutrelant L, Berdah P, Michaud P, Farah B, Mokhtari M, Makita Y, Michel PL, Luxereau P, Cormier B, Vahanian A. Late results of percutaneous mitral commissurotomy for calcific mitral stenosis. Am J Cardiol 2000; 85:1308-14. [PMID: 10831945 DOI: 10.1016/s0002-9149(00)00761-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The aim of this study was to assess late results of percutaneous mitral commissurotomy (PMC) in calcific mitral stenosis and to identify predictors to improve patient selection. We analyzed 422 patients who underwent PMC for calcific mitral stenosis. The extent of calcium was graded from 1 to 4 by fluoroscopy: 227 patients (53%) were graded 1, 125 (30%) graded 2, 55 graded 3 (13%), and 15 graded 4 (4%). The procedure failed in 15 patients, used a single balloon in 11, a double balloon in 126, and the Inoue balloon in 270. In-hospital mortality was 1.2%. Good immediate results (valve area >/=1.5 cm(2) without mitral regurgitation >2/4), were obtained in 321 patients (76%). Multivariate analysis identified 5 predictors of good immediate results: a younger age (p = 0.0004), a lesser degree of stenosis (p = 0.0005), a smaller extent of calcium (p = 0.04), the use of the Inoue balloon (p = 0.015), and a larger effective balloon dilating area (p = 0.006). Good functional results, defined as survival with no further intervention and in New York Heart Association class I or II, were 36 +/- 4% at 8 years. The predictors of good functional results after good immediate results were a younger age (p = 0.04), a lower pre-PMC New York Heart Association class (p <0.0001), sinus rhythm (p = 0.0006), a smaller extent of calcium (p = 0.02), and a lower gradient after PMC (p <0.0001). Despite a frequent deterioration on follow-up after PMC for calcific mitral stenosis, the predictive analysis suggests that PMC may be useful in deferring surgery in selected patients with mild to moderate calcific deposits, who have otherwise favorable characteristics.
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Affiliation(s)
- B Iung
- Bichat Hospital, Paris, France.
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31
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Kang DH, Park SW, Song JK, Kim HS, Hong MK, Kim JJ, Park SJ. Long-term clinical and echocardiographic outcome of percutaneous mitral valvuloplasty: randomized comparison of Inoue and double-balloon techniques. J Am Coll Cardiol 2000; 35:169-75. [PMID: 10636276 DOI: 10.1016/s0735-1097(99)00502-1] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The purpose of the present study was to compare the long-term clinical and echocardiographic results of the Inoue and the double-balloon techniques. BACKGROUND The large randomized trial comparing the extent of commissurotomy and the long-term results between the double-balloon and Inoue balloon techniques has not been reported. METHODS We conducted a prospective, randomized trial comparing two procedures in 302 consecutive patients who underwent percutaneous mitral valvuloplasty (PMV) using Inoue (n = 152; group I) or double-balloon technique (n = 150, group D) between 1989 and 1995. The sample size was planned to provide the study with approximately 80% power for the detection of a 10% difference between the two groups. RESULTS There were no significant differences in baseline characteristics between the two groups. Immediately after PMV, mitral valve area (MVA) increased from 0.9 +/- 0.2 to 1.8 +/- 0.3 cm2 in group I and from 0.9 +/- 0.2 to 1.9 +/- 0.3 cm2 in group D. No significant differences existed between the two groups in terms of development of commissural splitting, commissural mitral regurgitation (CMR), moderate to severe mitral regurgitation (MR) and MVA after PMV. The successful immediate results (MVA > or =1.5 cm2 and MR < or =2) were achieved in 127 (84%) patients of group I and 122 (81%) patients of group D (p = NS). Annual clinical and echocardiographic evaluation was completed for 290 (96%) patients with mean follow-up of 51 +/- 27 months. Adverse events occurred in 19 (13%) patients of group I (3 deaths, 7 mitral valve replacements, 5 repeat PMV, 2 NYHA class > or =3, 2 technical failures) and 16 (11%) patients of group D (2 deaths, 10 mitral valve replacements, 3 repeat PMV, 1 NYHA class > or =3). Estimated actuarial seven-year event-free survival was 75 +/- 7% in group I and 82 +/- 6% in group D (p = NS). Estimated actuarial seven-year restenosis-free survival was 67 +/- 7% in group I and 76 +/- 6% in group D (p = NS). On multivariate analysis, unsuccessful immediate result (p < 0.001) and absence of CMR (p < 0.01) were independently related with events. Absence of CMR and smaller mitral valve area after PMV were independently related with restenosis (p < 0.001). CONCLUSIONS The Inoue and double-balloon techniques were equally effective in commissurotomy and produced similar, excellent long-term results. The achievement of complete commissurotomy with development of CMR or larger post-PMV mitral valve area is important to optimize the long-term results of PMV.
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Affiliation(s)
- D H Kang
- Department of Internal Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea
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32
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Leon MN, Harrell LC, Simosa HF, Mahdi NA, Pathan A, Lopez-Cuellar J, Inglessis I, Moreno PR, Palacios IF. Mitral balloon valvotomy for patients with mitral stenosis in atrial fibrillation: immediate and long-term results. J Am Coll Cardiol 1999; 34:1145-52. [PMID: 10520804 DOI: 10.1016/s0735-1097(99)00310-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The purpose of this study was to examine the effect of atrial fibrillation (AF) on the immediate and long-term outcome of patients undergoing percutaneous mitral balloon valvuloplasty (PMV). BACKGROUND There is controversy as to whether the presence of AF has a direct negative effect on the outcome after PMV. METHODS The immediate procedural and the long-term clinical outcome after PMV of 355 patients with AF were prospectively collected and compared with those of 379 patients in normal sinus rhythm (NSR). RESULTS Patients with AF were older (62 +/- 12 vs. 48 +/- 14 years; p < 0.0001) and presented more frequently with New York Heart Association (NYHA) class IV (18.3% vs. 7.9%; p < 0.0001), echocardiographic score >8 (40.1% vs. 25.1%; p < 0.0001), calcified valves under fluoroscopy (32.4% vs. 18.8%, p < 0.0001) and with history of previous surgical commissurotomy (21.7% vs. 16.4%; p = 0.0002). In patients with AF, PMV resulted in inferior immediate and long-term outcomes, as reflected in a smaller post-PMV mitral valve area (1.7 +/- 0.7 vs. 2 +/- 0.7 cm2; p < 0.0001) and a lower event free survival (freedom of death, redo-PMV and mitral valve surgery) at a mean follow-up time of 60 months (32% vs. 61%; p < 0.0001). In the group of patients in AF, severe post-PMV mitral regurgitation (> or =3+) (p = 0.0001), echocardiographic score >8 (p = 0.004) and pre-PMV NYHA class IV (p = 0.046) were identified as independent predictors of combined events at follow-up. CONCLUSIONS Patients with AF have a worse immediate and long-term outcomes after PMV. However, the presence of AF by itself does not unfavorably influence the outcome, but is a marker for clinical and morphologic features associated with inferior results after PMV.
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Affiliation(s)
- M N Leon
- Department of Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston 02114, USA
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Garbarz E, Iung B, Cormier B, Vahanian A. Echocardiographic Criteria in Selection of Patients for Percutaneous Mitral Commissurotomy. Echocardiography 1999; 16:711-721. [PMID: 11175213 DOI: 10.1111/j.1540-8175.1999.tb00128.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The purpose of this report is to review the role of echocardiography in the selection of patients for percutaneous mitral commissurotomy (PMC). Echocardiography has become the standard for the assessment of the severity of mitral stenosis and of its consequences. PMC is usually performed only in patients with a valve area of < 1.5 cm(2), whereas pulmonary hypertension or spontaneous echo contrast in the left atrium may lead to intervention in patients with few symptoms. The next step of the echocardiographic evaluation is to eliminate contraindications: left atrial thrombosis (by the systematic performance of a transesophageal examination before PMC), mitral regurgitation >/= 2/4, severe aortic valve disease, mixed tricuspid valve disease, and massive or bicommissural calcification. Finally, echocardiography allows the classification of patients into different anatomic groups for prognostic consideration. There is controversy regarding the best echo score system in the prediction of the results of PMC. Scores using a global evaluation of the valve anatomy are the most widely used, whereas more recently, scores taking into account the uneven distribution of the disease have had promising preliminary results. Overall, echo scores are useful criteria for selecting candidates for PMC, but they should be considered together with the other clinical and procedural variables. Thus, echocardiography has an important role in the selection of patients for PMC, as well as for the guidance of the procedure, the evaluation of the results, and surveillance.
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Affiliation(s)
- Eric Garbarz
- Service de Cardiologie, Hopital Tenon, 4, rue de la Chine, 75020 Paris, France
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34
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Saeki F, Ishizaka Y, Tamura T. Long-term clinical and echocardiographic outcome in patients with mitral stenosis treated with percutaneous transvenous mitral commissurotomy. JAPANESE CIRCULATION JOURNAL 1999; 63:597-604. [PMID: 10478809 DOI: 10.1253/jcj.63.597] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Long-term follow-up after percutaneous transvenous mitral commissurotomy (PTMC) is limited. Ninety-four middle-aged (51+/-9 years) mitral stenosis patients who underwent successful PTMC were followed up with annual echocardiography for 6.1+/-1.4 years. PTMC success was defined as either mitral valve area (MVA) >1.5 cm2 or a MVA of more than twice the pre-procedural value, together with no worsening of mitral regurgitation >grade 2+. Mitral valve replacement (MVR), worsening of congestive heart failure (CHF), and thromboembolism were sought for survival analysis. Restenosis was defined as loss of more than 50% of the initial procedural MVA gain. Functional limit of daily activities was assessed through a questionnaire. The study population was divided into group 1 (post-procedural MVA >2.0 cm2), group 2 (MVA > 1.5 cm2 and < or = 2.0 cm2) and group 3 (MVA < or = 1.5 cm2). The 6-year survival with freedom from MVR, CHF, thromboembolism, and combined events (MVR+CHF) was 92%, 95%, 91%, and 88%, respectively. No group 1 patient experienced MVR or CHF. Restenosis was predominant in group 3. Deterioration of daily activities during follow-up was not observed in group 1; however, it was significant in group 2 (p<0.05) and group 3 (p<0.001). These results demonstrated that patients who attained a large MVA (>2.0cm2) immediately after PTMC maintained their procedural benefit with less clinical complication and with less limitation of daily activity.
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Affiliation(s)
- F Saeki
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
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35
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Hung JS, Lau KW, Lo PH, Chern MS, Wu JJ. Complications of Inoue balloon mitral commissurotomy: impact of operator experience and evolving technique. Am Heart J 1999; 138:114-21. [PMID: 10385773 DOI: 10.1016/s0002-8703(99)70255-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND There have been no single-center studies that have systematically addressed the acute outcome of Inoue balloon mitral commissurotomy (BMC) performed in a large series of patients. Accordingly, this study sought to examine the impact of operator experience and continuing technical modifications on the success and complication rates of BMC. METHODS BMC was performed in 799 patients: 469 patients with pliable mitral valves (group 1) and 330 patients with calcified valves and/or severe subvalvular disease (group 2). Acute complications were examined and compared between groups before and after modifications in BMC techniques. Major modifications included the use of a height-derived balloon sizing method for the selection of an appropriate balloon catheter, a cautionary stepwise dilation technique, and avoidance of traction on the interatrial septum during balloon inflations. RESULTS Technical failures were encountered in 4 (0.5%) patients in our early experience. One patient sustained cardiac perforation and tamponade and was the only case requiring emergency surgery. There were no deaths. Systemic embolic events were observed in 11 (1.4%), all among the first 353 patients before the routine use of pre-BMC transesophageal echocardiography. Severe postprocedure angiographic (>/=3+) mitral regurgitation occurred in 4% of patients, 2% in group 1 versus 9% in group 2 (P =.0001). With increased operator experience and technical modifications, this complication was significantly reduced from 5% (7 of 150 patients) to 0% in the last 316 patients in group 1 (P =.0001) and from 11% (26 of 228 patients) to 3% (3 of 101 patients) in group 2 (P =.031). The incidence of significant interatrial shunting (pulmonary-to-systemic flow ratio >/=1.3) was also significantly reduced from 12% to 6% (P =.0034). CONCLUSION Incremental operator experience and ongoing technical refinements in BMC techniques have resulted in a 100% technical success rate and a significant diminution in complications in patients with a wide spectrum of stenotic mitral valve morphologic features.
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Affiliation(s)
- J S Hung
- Section of Cardiology, China Medical College and Hospital, Taichung, Taiwan, Republic of China.
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36
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Pathan AZ, Mahdi NA, Leon MN, Lopez-Cuellar J, Simosa H, Block PC, Harrell L, Palacios IF. Is redo percutaneous mitral balloon valvuloplasty (PMV) indicated in patients with post-PMV mitral restenosis? J Am Coll Cardiol 1999; 34:49-54. [PMID: 10399991 DOI: 10.1016/s0735-1097(99)00176-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The purpose of this study was to assess the immediate and long-term outcome of repeat percutaneous mitral balloon valvuloplasty (PMV) for post-PMV mitral restenosis. BACKGROUND Symptomatic mitral restenosis develop in 7% to 21% of patients after PMV. Currently, most of these patients are referred for mitral valve replacement. However, it is unknown if these patients may benefit from repeat PMV. METHODS We report the immediate outcome and long-term clinical follow-up results of 36 patients (mean age 58+/-13 years, 75% women) with symptomatic mitral restenosis after prior PMV, who were treated with a repeat PMV at 34.6+/-28 months after the initial PMV. The mean follow-up period was 30+/-33 months with a maximal follow-up of 10 years. RESULTS An immediate procedural success was obtained in 75% patients. The overall survival rate was 74%, 72% and 71% at one, two, and three years respectively. The event-free survival rate was 61%, 54% and 47% at one, two, and three years respectively. In the presence of comorbid diseases (cardiac and noncardiac) the two-year event-free survival was reduced to 29% as compared with 86% in patients without comorbid diseases. Cox regression analysis identified the echocardiographic score (p = 0.03), post-PMV mitral valve area (p = 0.003), post-PMV mitral regurgitation grade (p = 0.02) and post-PMV pulmonary artery pressure (p = 0.0001) as independent predictors of event-free survival after repeat PMV. CONCLUSIONS Repeat PMV for post-PMV mitral restenosis results in good immediate and long-term outcome in patients with low echocardiographic scores and absence of comorbid diseases. Although the results are less favorable in patients with suboptimal characteristics, repeat PMV has a palliative role if the patients are not surgical candidates.
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Affiliation(s)
- A Z Pathan
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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37
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Iung B, Garbarz E, Michaud P, Helou S, Farah B, Berdah P, Michel PL, Cormier B, Vahanian A. Late results of percutaneous mitral commissurotomy in a series of 1024 patients. Analysis of late clinical deterioration: frequency, anatomic findings, and predictive factors. Circulation 1999; 99:3272-8. [PMID: 10385502 DOI: 10.1161/01.cir.99.25.3272] [Citation(s) in RCA: 153] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The optimal use of percutaneous mitral commissurotomy (PMC) in a wide range of patients requires accurate evaluation of late results and identification of their predictors. METHODS AND RESULTS Late results of PMC were assessed in 1024 patients whose mean age was 49+/-14 years. Echocardiography showed that 141 patients (14%) had pliable valves and mild subvalvular disease, 569 (55%) had extensive subvalvular disease, and 314 (31%) had calcified valves. A single balloon was used in 26 patients, a double balloon in 390, and the Inoue Balloon in 608. Good immediate results were defined as valve area >/=1.5 cm2 without regurgitation >2/4 (Sellers' grade) and were obtained in 912 patients. Median duration of follow-up was 49 months. The 10-year actuarial rate of good functional results (survival with no cardiovascular death and no need for surgery or repeat dilatation and in New York Heart Association [NYHA] class I or II) was 56+/-4% in the entire population. Follow-up echocardiography was available in 90% of the patients who experienced poor functional results after good immediate results and showed restenosis in 97% of these. In multivariate analysis, the predictors of poor functional results were old age (P=0.0008), unfavorable valve anatomy (P=0.003), high NYHA class (P<0.0001), atrial fibrillation (P<0.0001), low valve area after PMC (P=0.001), high gradient after PMC (P<0.0001), and grade 2 mitral regurgitation after PMC (P=0.04). CONCLUSIONS PMC can be performed with good late results in a variety of patient subsets. Prediction of late events is multifactorial. Knowledge of these predictors can improve patient selection and follow-up.
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Affiliation(s)
- B Iung
- Cardiology Department, Tenon Hospital, Paris, France
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38
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Leon MN, Harrell LC, Simosa HF, Mahdi NA, Pathan AZ, Lopez-Cuellar J, Palacios IF. Comparison of immediate and long-term results of mitral balloon valvotomy with the double-balloon versus Inoue techniques. Am J Cardiol 1999; 83:1356-63. [PMID: 10235095 DOI: 10.1016/s0002-9149(99)00100-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
There is controversy as to whether the double-balloon or Inoue technique of percutaneous mitral balloon valvotomy (PMBV) provides superior immediate and long-term results. This study compares the immediate procedural and long-term outcomes of patients undergoing PMBV using the double-balloon versus the Inoue techniques. Seven hundred thirty-four consecutive patients who underwent PMBV using the double-balloon (n = 621) or Inoue technique (n = 113) were studied. There were no statistically significant differences in baseline clinical and morphologic characteristics between the double-balloon and Inoue patients. The double-balloon technique resulted in superior immediate outcome, as reflected in a larger post-PMBV mitral valve area (1.9 +/- 0.7 vs 1.7 +/- 0.6 cm2; p = 0.005) and a lower incidence of 3+ mitral regurgitation after PMBV (5.4% vs 10.6%; p = 0.05). This superior immediate outcome of the double-balloon technique was observed only in the group of patients with echocardiographic score < or = 8 (post-PMBV mitral valve areas 2.1 +/- 0.7 vs 1.8 +/- 0.6; p = 0.004). Despite the difference in immediate outcome, there were no significant differences in event-free survival at long-term follow-up between the 2 techniques. Our study demonstrates that compared with the Inoue technique, the double-balloon technique results in a larger mitral valve area and less degree of severe mitral regurgitation after PMBV. Despite the difference in immediate outcome between both techniques, there were no significant differences in event-free survival at long-term follow-up.
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Affiliation(s)
- M N Leon
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston 02114, USA
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39
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Cribier A, Eltchaninoff H, Koning R, Rath PC, Arora R, Imam A, El-Sayed M, Dani S, Derumeaux G, Benichou J, Tron C, Janorkar S, Pontier G, Letac B. Percutaneous mechanical mitral commissurotomy with a newly designed metallic valvulotome: immediate results of the initial experience in 153 patients. Circulation 1999; 99:793-9. [PMID: 9989965 DOI: 10.1161/01.cir.99.6.793] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Percutaneous balloon valvotomy has become a common treatment of mitral stenosis, but the cost of the procedure remains a limitation in countries with restricted financial resources, leading to a frequent reuse of the disposable catheters. To overcome this limitation, a reusable metallic valvotomy device has been developed with the goals of both improving the mitral valvotomy results and decreasing the cost of the procedure. METHODS AND RESULTS The device consists of a detachable metallic cylinder with 2 articulated bars screwed onto the distal end of a disposable catheter whose proximal end is connected to an activating pliers. By the transseptal route, the device is advanced across the valve over a traction guidewire. Squeezing the pliers opens the bars up to a maximum extent of 40 mm. The clinical experience consisted of 153 patients with a broad spectrum of mitral valve deformities. The procedure was successful in 92% of cases and resulted in a significant increase in mitral valve area, from 0.95+/-0.2 to 2. 16+/-0.4 cm2. No increase in mitral regurgitation was noted in 80% of cases. Bilateral splitting of the commissures was observed in 87%. Complications were 2 cases of severe mitral regurgitation (1 requiring surgery), 1 pericardial tamponade, and 1 transient cerebrovascular embolic event. In this series, the maximum number of consecutive patients treated with the same device was 35. CONCLUSIONS The results obtained with this new device are encouraging and at least comparable to those of current balloon techniques. Multiple uses after sterilization should markedly decrease the procedural cost, a major advantage in countries with limited resources and high incidence of mitral stenosis.
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Affiliation(s)
- A Cribier
- Charles Nicolle Hospital, Department of Cardiology , University of Rouen, France.
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María Hernández García J, Horacio Alonso Briales J, José Gómez Doblas J, Luis Castillo Castro J, Álvarez de Cienfuegos Rivera F, Bullones Ramírez J, Álvarez Rubiera J, Rubio Alcaide Á, de Mora Martín M, Zafra Sánchez J, Urda Valcárcel T, Conejo Muñoz L, Malpartida de Torres F. Seguimiento actuarial tras valvulotomía mitral percutánea. Incidencia y factores predictores de eventos. Rev Esp Cardiol 1999. [DOI: 10.1016/s0300-8932(99)74958-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Sreenivas Kumar A, Kapoor A, Sinha N, Goel PK, Umeshan CV, Tiwari S, Shahi M. Influence of sub valvular pathology on immediate results and follow up events of Inoue balloon mitral valvotomy. Int J Cardiol 1998; 67:201-9. [PMID: 9894700 DOI: 10.1016/s0167-5273(98)00283-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We evaluated the influence of sub valvular pathology (SVP) on the immediate results and follow up events of Inoue Balloon Mitral Valvotomy (IBMY) in 206 patients with severe SVP (Group I) and compared their outcome with 206 age and sex matched patients selected from the rest of 619 patients having mild/moderate SVP (Group II). Pre-procedure echocardiographic recordings were reviewed and mitral valve morphology was evaluated using U.S. California Score. The severe SVP group had lower mitral valve areas (MVA) (0.7 cm2 vs. 0.8 cm2) and higher mean pulmonary artery pressure (MPAP) (46.3+/-16.9 mmHg vs. 40.7+/-16.25 mmHg) and mean pulmonary capillary wedge pressure (PCWP) (27.5+/-7.3 mmHg vs. 25.7+/-8.0 mmHg) (p<0.001). IBMV was done using standard technique. The procedure was technically successful in 192/206 patients (93.2%) in group I and 187/206 (91%) in group II (p=ns). The mean transmitral gradient decreased from 24.8+/-7.6 mmHg to 7.46+/-3.4 mmHg while mean PCWP fell from 27.5+/-7.3 mmHg to 12.2+/-5.6 mmHg and MPAP fell from 46.3+/-16.9 mmHg to 23.6+/-12.2 mmHg (p=<0.001). MVA increased from 0.7+/-0.2 cm2 to 1.7+/-0.4 cm2 (p=<0.001). Severe mitral regurgitation (MR) occurred in 2 patients out of which one patient, who had associated coronary artery disease, died post operatively, and moderate MR occurred in 8 patients. The results achieved in patients with severe SVP were not statistically different from those with mild/moderate SVP. The benefits achieved immediate post IBMV were sustained in 184 patients with severe SVP who were available for follow up at a mean duration of 15.2 months (range 3 months to 51 months). Thus IBMV is safe and effective in patients with severe SVP. This group of patients with severe SVP are more hemodynamically deranged pre-BMV and also achieve better hemodynamic benefit compared to those with mild/moderate SVP. Severe SVP does not have any adverse effect either on immediate results (success/occurrence of MR) or on intermediate term follow up.
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Affiliation(s)
- A Sreenivas Kumar
- Department of Cardiology, Sanjay Gandhi Post Graduate Institute Lucknow, India
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Stefanadis CI, Stratos CG, Lambrou SG, Bahl VK, Cokkinos DV, Voudris VA, Foussas SG, Tsioufis CP, Toutouzas PK. Retrograde nontransseptal balloon mitral valvuloplasty: immediate results and intermediate long-term outcome in 441 cases--a multicenter experience. J Am Coll Cardiol 1998; 32:1009-16. [PMID: 9768726 DOI: 10.1016/s0735-1097(98)00357-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Our aim was to present the immediate and intermediate long-term results of the application of retrograde nontransseptal balloon mitral valvuloplasty (RNBMV) in four cooperating centers from Greece and India. BACKGROUND RNBMV is a purely transarterial method of balloon valvuloplasty, developed with the aim to avoid complications associated with transseptal catheterization. Only single-center experience with RNBMV has been previously reported. METHODS The procedure was attempted in 441 patients with symptomatic mitral stenosis (320 women, 121 men, mean age [+/-SD] 44+/-11 years, mean echocardiographic score [+/-SD] 7.7+/-2.0) from 1988 to 1996. Three hundred eighty-five patients with successful immediate outcome were followed clinically for a mean [+/-SD] of 3.5+/-1.9 (range, 0.5-9.1) years. RESULTS A technically successful procedure was achieved in 388 (88%) cases. The echocardiographic score (p < 0.001), male gender (p=0.005), preprocedural mitral regurgitation (p=0.007) and previous surgical commissurotomy (p=0.029) were unfavorable predictors of immediate outcome. Complications included death (0.2%), severe mitral regurgitation (3.4%) and injury of the femoral artery (1.1%). Event-free (freedom from cardiac death, mitral valve surgery, repeat valvuloplasty and NYHA class > II symptoms) survival rates (+/-SEM) were 100%, 96.9+/-0.9%, 89.8+/-1.9% and 75.5+/-5.5% at 1, 2, 4 and 9 years, respectively. The echocardiographic score (p < 0.001), NYHA class (p=0.008) and postprocedural mitral valve area (p=0.009) were significant independent predictors of intermediate long-term outcome. CONCLUSIONS Multicenter experience indicates that RNBMV is a safe and effective technique for the treatment of symptomatic mitral stenosis. As with the transseptal approach, patients with favorable mitral valve anatomy derive the greatest immediate and intermediate long-term benefit from this procedure.
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Affiliation(s)
- C I Stefanadis
- Department of Cardiology of Athens University, Hippocration Hospital, Greece
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Osa A, Almenar L, Rincón de Arellano A, Martí S, Roldán I, Mora V, Palencia M, Algarra F. [Long-term results of percutaneous mitral valvuloplasty]. Rev Esp Cardiol 1998; 51:458-66. [PMID: 9666697 DOI: 10.1016/s0300-8932(98)74774-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The aim of this study was to assess the long-term results of percutaneous transvenous mitral commisurotomy in our institution, and to evaluate potential predictors of long-term event-free survival. PATIENTS AND METHODS Between 1990 and 1996, 204 patients underwent percutaneous transvenous mitral commisurotomy with an Inoue balloon. One hundred and thirty two patients were followed for up to 9 months. Mean time of follow-up was 2.6-1.5 years (7 days-5.7 years). End points were considered mitral surgery, death and functional class III-IV. Long-term event-free survival analysis was performed to determine independent predictors of event-free survival. RESULTS At the end of the study, 88% of patients were classified as New York Heart Association class I-II. Multivariate analysis revealed that independent predictors of major events were stiffness and thickening of the valve, presence of severe left atrial enlargement as factors pre-procedure; with suboptimal results and significant mitral regurgitation after percutaneous transvenous mitral commisurotomy. CONCLUSIONS Percutaneous transvenous mitral commisurotomy with Inoue balloon is a safe and effective technique. Good results are maintained at long-term follow-up and the best results are obtained in patients with flexible and thin valves, with mild or moderate enlargement of left auricle and in cases with optimal results and without severe mitral regurgitation as a complication of the procedure.
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Affiliation(s)
- A Osa
- Servicio de Cardiología, Hospital Universitario La Fe, Valencia.
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Kothari SS, Kamath P, Juneja R, Bahl VK, Airan B. Percutaneous transvenous mitral commissurotomy using Inoue balloon in children less than 12 years. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1998; 43:408-11. [PMID: 9554766 DOI: 10.1002/(sici)1097-0304(199804)43:4<408::aid-ccd10>3.0.co;2-f] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Rheumatic mitral stenosis in some parts of the world afflicts even young children. Percutaneous transvenous mitral commissurotomy (PTMC) using Inoue balloon in these children is not well reported. Forty-five children (aged 7-12 years, mean 11.0 +/- 1.2 years) with severe rheumatic mitral stenosis (mitral valve area [MVA] 0.64 +/- 0.14 cm2) underwent PTMC. The pulmonary artery wedge pressure (PAW) decreased from 24.3 +/- 8.6 to 14.7 +/- 7.2 mmHg (P < 0.0001) and mean diastolic gradient decreased from 24.3 +/- 7.7 to 7.9 +/- 5.9 mmHg with the final MVA of 1.63 +/- 0.45 cm2 (P < 0.0001). Complications included significant mitral regurgitation (MR) in three children and atrial shunting in two patients. No procedural death, systemic embolism, and cardiac tamponade were encountered. Twenty-four children had maximum balloon size (MBS) same as recommended balloon size (RBS) derived according to the height (group I) and 21 children had MBS 1-3 mm less than RBS (group II). Despite the lesser maximum balloon size, the final results were comparable in both groups (MVA group 1.66 +/- 0.44 vs. group II 1.61 +/- 0.48 P = NS). The incidence of significant MR (2 and 1 in group I and group II, respectively) was similar. On follow-up of 20.4 +/- 16.3 months (range 3-56 months), one child developed restenosis. We conclude that PTMC is safe and effective in children less than 12 years of age. However, the smaller balloon size than the RBS derived from height may be equally effective and possibly safer.
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Affiliation(s)
- S S Kothari
- Department of Cardiology, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi.
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Allen HD, Beekman RH, Garson A, Hijazi ZM, Mullins C, O'Laughlin MP, Taubert KA. Pediatric therapeutic cardiac catheterization: a statement for healthcare professionals from the Council on Cardiovascular Disease in the Young, American Heart Association. Circulation 1998; 97:609-25. [PMID: 9494035 DOI: 10.1161/01.cir.97.6.609] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Goel PK, Garg N, Sinha N. Pressure zone used and the occurrence of mitral regurgitation in Inoue balloon mitral commissurotomy. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1998; 43:141-6. [PMID: 9488544 DOI: 10.1002/(sici)1097-0304(199802)43:2<141::aid-ccd7>3.0.co;2-a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Mitral regurgitation (MR) is a known complication of Inoue balloon mitral commissurotomy (BMC) and has been variously ascribed to the presence of severe subvalvular pathology (SVP), preexisting MR, calcification, or oversizing. The pressure zone used--with the low pressure zone (LPZ) the lower half of the spectrum of sizes available out of a single balloon, and the high pressure zone (HPZ) the upper two levels, i.e., within 2 mm of its maximum size--could have a bearing on the occurrence of MR, but has not been studied before. We analysed 251 consecutive patients (mean age 28.6 + 9.7 years), undergoing BMC from October 1993 onwards, with pliable, non-calcific, splittable (bilateral dark zones present) valves with not more than trivial MR (1 + in grades of 1-4). Balloon sizing was done with standard formula using height with stepwise dilatation starting 2 mm below the reference size. Thirty-two patients additionally had severe SVP. Patients were divided into two groups, HPZ-BMC and LPZ-BMC, depending upon the final balloon size needed for a successful result. Incidence of MR (2+ or more) was significantly lower in the LPZ BMC (18%) vs. HPZ BMC (32.2%) (P < 0.05). Moderate to severe MR (3+/4+) was also less in LPZ BMC (2.8%) vs. HPZ BMC (8.2%) (P < 0.05). Amongst patients with severe SVP, 3/15 (20%) developed MR in the LPZ-BMC group (all mild only) as against 8/17 (42%) (P < 0.05) in the HPZ-BMC group with half of them having moderate to severe MR. In 54 patients where the reference size had to be exceeded, no patient (0/8) developed MR as long as the higher size was in the LPZ of the particular balloon used as compared to 17/46 (36.9%) who developed MR when the size used fell in the HPZ. We conclude that the pressure zone used has a strong bearing on the occurrence of MR in Inoue BMC and that a low-pressure strategy could avoid MR.
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Affiliation(s)
- P K Goel
- Department of Cardiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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Ben Farhat M, Ayari M, Maatouk F, Betbout F, Gamra H, Jarra M, Tiss M, Hammami S, Thaalbi R, Addad F. Percutaneous balloon versus surgical closed and open mitral commissurotomy: seven-year follow-up results of a randomized trial. Circulation 1998; 97:245-50. [PMID: 9462525 DOI: 10.1161/01.cir.97.3.245] [Citation(s) in RCA: 199] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Percutaneous balloon mitral commissurotomy (BMC) has been proposed as an alternative to surgical closed mitral commissurotomy (CMC) and open mitral commissurotomy (OMC) for the management of rheumatic mitral valve stenosis (MS). METHODS AND RESULTS We conducted a prospective, randomized trial comparing the results of the 3 procedures in 90 patients (30 patients in each group) with severe pliable MS. Cardiac catheterization was performed in all patients before and at 6 months after each procedure. All patients had clinical and echocardiographic evaluation initially and throughout the 7-year follow-up period. Gorlin mitral valve area (MVA) increased much more after BMC (from 0.9+/-0.16 to 2.2+/-0.4 cm2) and OMC (from 0.9+/-0.2 to 2.2+/-0.4 cm2) than after CMC (from 0.9+/-0.2 to 1.6+/-0.4 cm2). Residual MS (MVA <1.5 cm2) was 0% after BMC or OMC and 27% after CMC. There was no early or late mortality or thromboembolism among the three groups. At 7-year follow-up, echocardiographic MVA was similar and greater after BMC and OMC (1.8+/-0.4 cm2) than after CMC (1.3+/-0.3 cm2; P<.00l). Restenosis (MVA <1.5 cm2) rate was 6.6% after BMC or OMC versus 37% after CMC. Residual atrial septal defect was present in 2 patients and severe grade 3 mitral regurgitation was present in 1 patient in the BMC group. Eighty-seven percent of patients after BMC and 90% of patients after OMC were in New York Heart Association functional class I versus 33% (P<.0001) after CMC. Freedom from reintervention was 90% after BMC, 93% after OMC, and 50% after CMC. CONCLUSIONS In contrast to surgical CMC, BMC and OMC produce excellent and comparable early hemodynamic improvement and are associated with a lower rate of residual stenosis and restenosis and need for reintervention. However, the good results, lower cost, and elimination of drawbacks of thoracotomy and cardiopulmonary bypass indicate that BMC should be the treatment of choice for patients with tight pliable rheumatic MS.
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Affiliation(s)
- M Ben Farhat
- Department of Medicine, Fattouma Bourguiba University Hospital, Monastir, Tunisia
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Cheng TO. Percutaneous balloon mitral valvuloplasty or percutaneous balloon mitral commissurotomy? CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1998; 43:39-41. [PMID: 9473185 DOI: 10.1002/(sici)1097-0304(199801)43:1<39::aid-ccd10>3.0.co;2-o] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Wang A, Bashore TM. Cardiac perforation and tamponade: being at the wrong place but at predictable times during balloon mitral commissurotomy. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1997; 42:149-50. [PMID: 9328697 DOI: 10.1002/(sici)1097-0304(199710)42:2<149::aid-ccd11>3.0.co;2-j] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Abstract
Percutaneous balloon mitral valvuloplasty, first performed by Inoue in 1982, was a rational progression from 4 decades of experience with the blunt surgical dilatation technique of closed mitral commissurotomy. As with surgical commissurotomy, balloon valvuloplasty relieves mitral stenosis by the splitting of fused commissures. A series of studies have shown that balloon valvuloplasty achieves excellent acute hemodynamic results in close to 90% of patients, with a typical 100% increase in mitral valve area. Over the past 15 years since Inoue's first patient, a number of other techniques have been introduced and largely discarded in favor of the original approach. Advances have occurred along the lines of improved noninvasive assessment of mitral valve disease, which have allowed better case selection and prediction of outcome. Follow-up series have shown sustained improvement, with modest rates of complications and restenosis. Comparative studies have shown that balloon valvuloplasty is as effective and safe as surgical commissurotomy, and is a cost-effective procedure of first choice in ideal patients.
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Affiliation(s)
- J J Glazier
- Department of Medicine, Harper Hospital/Wayne State University, Detroit, MI, USA
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