Comparison of mitral valve area results of balloon mitral valvotomy using the Inoue and double balloon techniques

Late outcome of percutaneous mitral commissurotomy: Randomized comparison of Inoue versus double-balloon technique

BACKGROUND

Late prognosis after successful percutaneous mitral commissurotomy (PMC) is unclear. We compared late results of PMC using Inoue versus double-balloon techniques up to 25 years in a randomized trial.

METHODS

Between 1989 and 1995, 302 patients (77 men, 41 ± 11 years) with severe mitral stenosis were randomly assigned to undergo PMC using Inoue (n = 152; group I) or double-balloon technique (n = 150; group D). The end points were the composite events of death, mitral surgery, repeat PMC, or deterioration of New York Heart Association (NYHA) class ≥3.

RESULTS

During median follow-up of 20.7 years (maximum, 25.6), clinical events occurred in 82 (53.9%) patients in group I (37 deaths, 44 mitral surgeries, 9 repeat PMCs, 3 NYHA class ≥3) and in 79 (52.7%) patients in group D (34 deaths, 51 mitral surgeries, 5 repeat PMCs, 4 NYHA class ≥3). Event-free survival rates at 24 years were not significantly different between group I and group D (40.8% and 42.6%, respectively; hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.65-1.20; P = .423). On multivariate analysis, absence of post-PMC commissural mitral regurgitation (MR) (HR, 1.84; 95% CI, 1.28-2.63; P = .001) and immediate post-PMC mitral valve area (MVA) <1.8 cm² (HR, 1.53; 95% CI, 1.04-2.25; P = .031) were independently correlated with clinical events after successful PMC.

CONCLUSIONS

The Inoue and double-balloon methods showed similar good clinical outcomes up to 25 years, and the achievement of effective commissurotomy to develop post-PMC commissural MR or immediate post-PMC MVA ≥1.8 cm² is important in optimizing the late results of PMC.

Clinical and Echocardiographic Follow-up after Successful Percutaneous Transvenous Mitral Commissurotomy

Background

The objective of the study was to determine the long-term outcomes, including mitral restenosis and regurgitation, after successful percutaneous transvenous mitral commissurotomy (PTMC).

Methods

This cross-sectional prospective study was conducted at the cardiology department of Lady Reading Hospital, Peshawar, Pakistan, from January 2007 to December 2009. A total of 84 patients were followed up for a period of 96 months. Pre and post percutaneous transvenous mitral commissurotomy echocardiography was done on the mitral valve area (MVA) using two-dimensional (2D) and color doppler echocardiography. Patients who had successful PTMC were followed up for MVA loss, mitral regurgitation (MR), and cardiac death. SPSS Software (IBM SPSS Statistics for Windows, Version 22.0, Armonk, NY: IBM Corp.; 2013) was used for data analysis.

Results

Of the 84 patients, 21 were male, and 63 were females. The mean age was 35 ± 11 years. After PTMC, the mean valve two-dimensional area increased from 0.84 ± 0.13 to 1.83 ± 0.49 cm² (p value <0.001). MR was mild in 49 patients (62.8%), moderate in 27 patients (34.6%), and severe in two patients (2.6%). Good results were achieved in 60 (71.4%). Patients with good results were younger (24 ± 4), and had a relatively lower Wilkin's score, with a mean value of (8.4 ± 2.8). Follow-up events were death in six patients, mitral valve replacement (MVR) in 10 patients, and restenosis in seven patients. The Kaplan-Meier curve was used for the follow-up end points. Patient who required PTMC for mitral restenosis survived for a longer time than those requiring MVR, and those who had cardiac death due to severe pulmonary hypertension or heart failure.

Conclusion

Patients who had favorable Wilkin’s score and underwent PTMC for severe symptomatic mitral stenosis had better event-free survival in the long term follow-up.

Percutaneous mitral balloon valvuloplasty

Almost all mitral stenosis (MS) is rheumatic in etiology. The patient with MS who is symptomatic despite medical therapy should undergo percutaneous mitral balloon valvuloplasty or mitral valvular surgery (commissurotomy or replacement). The choice of procedure is determined by patient preference and the echocardiographic morphologic features of the valvular and subvalvular apparati. With balloon valvuloplasty, the rate of success is > 90%. At institutions where operators are experienced with balloon valvuloplasty and open surgical commissurotomy, their acute and long-term results are comparable. Balloon valvuloplasty occasionally is associated with complications, including death in 0 to 1%, moderate or severe valvular regurgitation in 3 to 5%, and systemic embolization in 1 to 3%.

Long-term clinical and echocardiographic outcome of percutaneous mitral valvuloplasty: randomized comparison of Inoue and double-balloon techniques

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.

Long-term results of percutaneous balloon mitral valvuloplasty for mitral stenosis: a follow-up study to 11 years in 202 patients

We studied the first 202 patients with rheumatic mitral stenosis (MS) who underwent percutaneous balloon mitral valvuloplasty (PBMV) with the Inoue balloon catheter for a follow-up (FU) period of 5-11 years. Pre- and post-PBMV and at FU, the mean left atrial pressure was 21.3+/-7.4, 10.2+/-5.6, and 11.2+/-4.1 mm Hg; mean diastolic mitral gradient was 18.4+/-7.3, 2.9+/-3.2, and 5.1+/-4.3 mm Hg; and mitral valve area was 1.0+/-0.3, 2.1+/-0.6, and 1.7+/-0.5 cm2. Functional status improved from New York Heart Association (NYHA) class IV in 3, class III in 119, and class II in 80 pre-PBMV to class I in 163, class II in 37, and class III in 2 post-PBMV, and was class I in 146, class II in 39, and class III in 17 patients at FU. In the 17 patients with NYHA class III at FU, mitral restenosis was the culprit; 4 underwent repeat PBMV, 12 had mitral valve replacement for severe mitral calcification and subvalvular fusion, and 1 refused further intervention. Thus PBMV using the Inoue balloon catheter is an effective method of relieving MS with excellent long-term results in patients without severe mitral calcification and subvalvular fusion.

Percutaneous balloon mitral valvuloplasty

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.

Inoue balloon deformity and rupture during percutaneous balloon valvuloplasty

In the management of mitral stenosis, similar long-term results can be obtained by using either an Inoue balloon catheter or a double-balloon technique for percutaneous balloon valvuloplasty. There have been few reports concerning any deformity of an Inoue balloon. From January 1988 to June 1995, 263 procedures of either mitral or tricuspid valvuloplasty have been performed in this center. The Inoue balloon catheter technique was used for 245 procedures. A deformity of the Inoue balloon catheter was noted in 4 (1.6%) and actual rupture of deformed balloon occurred in one (0.4%). All deformities were found at the distal portion of the Inoue balloon. Valvular insufficiency became more severe after valvuloplasty in two cases. Following rupture of the balloon, neither arterial embolization nor perforation of the cardiac chambers developed. In conclusion, a deformity of the Inoue balloon, although rare, can develop during percutaneous balloon valvuloplasty. The deformity may portend balloon rupture if additional maximal dilatations are undertaken.

Advantage of Inoue balloon catheter in mitral balloon valvotomy: experience with 220 consecutive patients

Percutaneous mitral balloon valvotomy (PMV) using the Inoue balloon catheter was attempted in 220 consecutive patients with severe symptomatic mitral stenosis. Their age range was 10-63 mean 30 +/- 10 years; 161 patients were females and 59 were males; 29 patients were in atrial fibrillation. Eleven patients were pregnant; 14 patients underwent previous surgical commissurotomy. The procedure was technically successfully performed in 215 (97.7%) patients. The mean fluoroscopy time was 15.5 +/- 6.4 min and mean procedure time was 109 +/- 79 min. Optimal results (group I) was achieved in 207 patients who have mitral score of 7 +/- 1. PMV resulted in decrease in left atrial pressure from 23 +/- 5 to 14 +/- 4 mm Hg (P < 0.001), the mean mitral valve gradient (MVG) decreased from 15 +/- 4 to 6 +/- 3 mm Hg (P < 0.001). The mitral valve area (MVA) by catheter increased from 0.7 +/- 0.2 to 1.7 +/- 0.5 cm2 (P < 0.001) and MVA as determined by echocardiography (2DE) increased from 0.8 +/- 0.1 to 1.9 +/- 0.3 cm2 (P < 0.001). The results were suboptimal in eight patients who have a mitral score of 10 +/- 1 (group II) MVA by catheter increased from 0.7 +/- 0.2 to 1 +/- 0.1 cm2 and Doppler MVA increased from 0.8 +/- 0.1 to 1.3 +/- 0.1 cm2. There were no deaths or thromboembolism. Two patients developed cardiac tamponade; mild mitral regurgitation (MR) developed in 24 patients (11%) and increased by one grade in another 22 patients (10%). Severe MR was encountered in three patients (1.4%). A small ASD (QP/QS < or = 1.3) was detected by oximetry in 5% of patients and by color-flow mapping in 26% of patients. One hundred fifty-eight patients from group I were followed up, for a mean of 32 +/- 12 months; MVA remained at 1.7 +/- 0.4 cm2. Seven patients developed mitral restenosis in group I, and 5 out of 8 patients developed restenosis in group II. We conclude that the hemodynamic results are good and comparable with those reported with double balloon technique. However, the Inoue balloon has several advantages over the double balloon technique: (1) low incidence of mitral regurgitation and ASDs; (2) shorter procedure and fluoroscopy time; and (3) low complication rates and the valve anatomy affects the immediate and late outcome of mitral balloon valvotomy.

Immediate and long-term results of balloon mitral commissurotomy for rheumatic mitral stenosis: comparison between Inoue and double-balloon techniques

We examined the immediate results and 2-year follow-up of percutaneous transvenous mitral commissurotomy (PTMC) using the Inoue balloon (IB) and double-balloon (DB) techniques. Short-term comparisons have been described, but long-term comparisons have not been available. PTMC was performed in 208 adult patients with symptomatic mitral stenosis (MS) and mitral valve area (MVA) of 0.94 +/- 0.2 cm2, by use of the IB in 157 (73.4%) and the DB technique in 56 (26.3%). Procedures were performed successfully and without complications in 198 (93%) cases. Adequate mitral dilatation (MVA = 1.6 cm2) without significant regurgitation was obtained in 179 (86%) of 192 patients. The final MVA was 2.0 +/- 0.43 cm2 after IB and 2.06 +/- 0.51 cm2 after DB (not significant). Technical difficulties and complications were more frequent with DB (16% vs 3.8%; p<0.001). Severe mitral regurgitation (grade III to IV) occurred in 4.6% of IB and 4.1% of DB (not significant), whereas grade 1 mitral regurgitation was greater with IB (21% vs 10.2%; p=0.01). A total of 172 patients were monitored an average of 23.8 +/- 10.6 months, with 83% in New York Heart Association functional class 1, echocardiographic MVA of 1.84 +/- 0.44 cm2, and restenosis rate of 22% at 36 months. PTMC is a safe, effective treatment for symptomatic MS. Results of both IB and DB techniques are similar, but the IB is simpler and safer, Long-term clinical improvement is maintained, although the restenosis rate seems to be progressive and related to inadequate immediate results.

Pitfalls and tips in inoue balloon mitral commissurotomy

Balloon mitral commissurotomy is a safe and effective alternative therapeutic modality in selected patients with significant rheumatic mitral stenosis. Since its introduction in 1984, Inoue balloon mitral commissurotomy has gained wider acceptance over other balloon valvuloplasty techniques because it is technically less demanding and associated with fewer complications. Nevertheless, certain pitfalls which may make the procedure more difficult or create complications are sometimes encountered. In this article, we offer tips to facilitate a safe and expeditious execution of Inoue balloon mitral commissurotomy based on our experience with over 1,000 procedures.

Comparison of late outcome between Inoue balloon and double-balloon techniques for percutaneous mitral valvotomy in a matched study

The follow-up results between Inoue balloon (n = 43, group 1) and double-balloon (n = 43, group 2) mitral valvotomies were compared in a patient-to-patient matched study. Matching was based on patients' age, mitral valve echo score, fluoroscopic calcification, mitral valve area before valvotomy, and follow-up period. The mean follow-up period was 13 +/- 9 months for both groups. At follow-up, 72% of patients were symptom free in each group; 2 (4.7%) patients in group 1 and 1 (2.3%) patient in group 2 underwent mitral valve replacement surgery. Of these 3 patients, 2 died after surgery, 1 from each group. The mitral valve area by Doppler was 1.8 +/- 0.3 cm2 in group 1 and 1.8 +/- 0.4 cm2 in group 2 (p = 0.7); the area by echo planimetry was 1.7 +/- 0.3 cm2 in group 1 and 1.8 +/- 0.3 cm2 in group 2 (p = 0.3) at follow-up. Restenosis occurred in 5 (12%) patients from each group. The cumulative restenosis-free rate was 96% at 1 years, 78% at 2 years, and 58% at 3 years in group 1 and 98%, 76%, and 51%, respectively, in group 2 (p = 0.8). Balloon selection did not appear to influence the clinical outcome at follow-up. We conclude that both the inoue balloon and the double-balloon valvotomies are effective therapies with comparable follow-up results for patients with mitral stenosis.

Percutaneous balloon mitral valvuloplasty by the Inoue technique: a multicenter study of 4832 patients in China

Between November 1985 and January 1994, 4832 patients with rheumatic mitral stenosis from 120 medical centers in China underwent PBMV by the Inoue technic. There were 1440 men and 3392 women with a mean age of 36.8 +/- 12.3 years. The procedure success rate was 99.30%. Major complications included death in 0.12%, > or = 3+/4+ mitral regurgitation in 1.41%, cardiac tamponade in 0.81%, and thromboembolism in 0.48%. After PBMV, the mean left atrial pressure decreased from 26.2 +/- 7.6 mm Hg to 11.4 +/- 6.1 mm Hg (p < 0.001); mean mitral diastolic gradient decreased from 18.3 +/- 5.1 mm Hg to 5.4 +/- 3.1 mm Hg (p < 0.001); pulmonary artery systolic pressure decreased from 51.2 +/- 14.8 mm Hg to 33.9 +/- 8.8 mm Hg (p < 0.001); cardiac output increased from 3.8 +/- 1.3 L/min to 4.8 +/- 1.2 L/min (p < 0.001); and mitral valve area expanded from 1.1 +/- 0.3 cm2 to 2.1 +/- 0.2 cm2 (p < 0.001). Functional status was NYHA class IV in 5.6%, class III in 38.8%, class II in 55.5%, and class I in 0.1% of patients before PBMV and improved to class I in 75.8%, class II in 23%, and class III in 1.2% after PBMV. The rate of restenosis was 5.2% over a follow-up period of 32.2 +/- 14.2 months in the entire group and 4.6% over a follow-up period of 5.1 +/- 1.0 years in Guangdong Cardiovascular Institute, where PBMV was begun in China.(ABSTRACT TRUNCATED AT 250 WORDS)

Controversies in balloon mitral valvuloplasty: the when (timing for intervention), what (choice of valve), and how (selection of technique)

Despite the established role of percutaneous balloon mitral valvuloplasty (BMV) in the treatment of mitral stenosis, major controversial issues in the realm of BMV persist. With increased operator experience, BMV has now been extended to include various controversial scenarios, such as mild mitral stenosis, adverse valve morphologies, and high-risk patients with concomitant anatomic distortions which are technically demanding. In skilled hands, however, BMV has yielded a favorable outcome in these settings. Furthermore, the debate on whether the Inoue or the double-balloon approach is superior continues. Studies to date have shown equal efficacy of the two BMV methods in terms of valve enlargement although the Inoue approach is clearly simpler to execute and may potentially be associated with a lower risk of creating severe mitral regurgitation. Last, because of the lack of consensus on optimal balloon sizing for BMV, perhaps the best method to adopt at this stage is one that is simple and safe to apply across a broad spectrum of valve anatomy.

Inoue balloon rupture during dilatation of calcified mitral valves

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Retrograde nontransseptal balloon mitral valvuloplasty using a modified Inoue balloon catheter

Retrograde nontransseptal balloon mitral valvuloplasty, a method developed in our institution for the treatment of symptomatic mitral stenosis, avoids transseptal catheterization. Until recently, the self-positioning Inoue balloon catheter, unlike all other commercially available balloon catheters, had not been employed in this nontransseptal technique due to the short length of its catheter shaft. To employ a self-positioning balloon in retrograde nontransseptal balloon mitral valvuloplasty, we modified the Inoue device by extension of the catheter shaft. After retrograde nontransseptal left atrial catheterization using a steerable cardiac catheter, the modified Inoue balloon catheter was inserted through the femoral artery and advanced to the mitral valve retrogradely. Valvuloplasty was performed in 20 patients, with a successful result achieved in all. The modified Inoue balloon catheter was easy to use in retrograde nontransseptal balloon mitral valvuloplasty and showed excellent stability during inflation. Mean mitral valve area increased from 1.0 +/- 0.29 to 2.23 +/- 0.64 cm2 (P < 0.001) and mean transmitral gradient decreased from 11.4 +/- 6 to 4.3 +/- 2.1 mm Hg (P < 0.001). No major or minor complications were observed. Retrograde nontransseptal balloon mitral valvuloplasty using a modified Inoue balloon catheter is a feasible and effective technique for the treatment of symptomatic mitral stenosis. It appears to combine the advantages of avoiding transseptal catheterization with the advantages of this balloon's special configuration.

A comparison of cylindrical and Inoue balloon techniques for mitral valvotomy in patients in the United Kingdom

OBJECTIVES

To compare the use of cylindrical balloons and the Inoue balloon for percutaneous mitral valvotomy in patients in the United Kingdom.

DESIGN

Comparison of the haemodynamic results, complications, and symptomatic outcome of balloon dilatation for mitral stenosis in consecutive patients treated by cylindrical balloons and a second consecutive series of patients treated by the Inoue balloon.

SETTING

A tertiary cardiac referral centre in Scotland.

PATIENTS

70 patients (mean age 60.6 years) treated by the single or double cylindrical balloon technique and 70 patients (mean age 58.9 years) treated with the Inoue balloon method.

MAIN OUTCOME MEASURES

Success in obtaining dilatation at the mitral orifice, procedure and screening times, increase in valve area, complications, and early symptomatic outcome.

RESULTS

Dilatation of the mitral valve was obtained in 91% of patients when cylindrical balloons were used and in 99% of patients treated with the Inoue balloon. Use of the Inoue balloon gave significantly shorter procedure and screening times. Technical problems in obtaining and maintaining the position at the mitral orifice were more common with cylindrical balloons. Improvements in valve area and symptoms were not significantly different with use of the two types of balloon. The Inoue balloon avoided cardiac tamponade and the creation of larger atrial septal defects, but had a higher incidence of increase in mitral reflux.

CONCLUSIONS

In these elderly patients, the Inoue balloon method was safer and faster for percutaneous mitral valvotomy, with a higher success rate for dilatation within the valve orifice. Haemodynamic and symptomatic improvement was similar with the two techniques.

Percutaneous balloon valvuloplasty compared with open surgical commissurotomy for mitral stenosis

BACKGROUND

Percutaneous balloon mitral valvuloplasty has been proposed as an alternative to open surgical commissurotomy for the treatment of rheumatic mitral-valve stenosis.

METHODS

We enrolled 60 patients with severe mitral stenosis and favorable valvular anatomy in a prospective, randomized trial comparing the two procedures. All patients underwent cardiac catheterization before the procedure and one week, six months, and three years thereafter. Hemodynamic data were analyzed by investigators who were blinded to the patients' treatment assignments.

RESULTS

Mitral-valve areas improved initially in both groups, from a mean (+/- SD) of 0.9 +/- 0.3 cm2 to 2.1 +/- 0.6 cm2 in the balloon-valvuloplasty group (30 patients; P < 0.01) and from 0.9 +/- 0.3 cm2 to 2.0 +/- 0.6 cm2 in the surgical group (30 patients; P < 0.001). Although improvement was maintained in both groups, mitral-valve areas were greater in the patients in the balloon-valvuloplasty group at three years (2.4 +/- 0.6 cm2, vs. 1.8 +/- 0.4 cm2 in the surgery group, P < 0.001). Restenosis occurred in three patients in the balloon-valvuloplasty group and four in the surgery group. One patient in the balloon-valvuloplasty group died of an apparent stroke after 2.5 years; four patients in the balloon-valvuloplasty group had residual atrial septal defects, and three patients (two in the balloon-valvuloplasty group and one in the surgery group) were judged to have severe mitral regurgitation. Seventy-two percent of the patients who underwent balloon valvuloplasty and 57 percent of the surgically treated patients were in New York Heart Association functional class I (i.e., they had no cardiovascular symptoms) at three years. No patient was lost to follow-up.

CONCLUSIONS

In the treatment of mitral stenosis, balloon valvuloplasty and open surgical commissurotomy have comparable initial results and low rates of restenosis, and both produce good functional capacity for at least three years. The potential complications associated with balloon valvuloplasty should be noted. The better hemodynamic results at three years, lower cost, and elimination of the need for thoracotomy suggest that balloon valvuloplasty should be considered for all patients with favorable mitral-valve anatomy.

Percutaneous transvenous mitral commissurotomy in 390 cases using the Inoue balloon catheter

Percutaneous transvenous mitral commissurotomy using the Inoue technique was performed in 390 cases of rheumatic mitral stenosis. There were 220 (56%) females and 170 (44%) males. The age range was 9-47 years [mean +/- S.D., 26 +/- 14) and all were symptomatic (New York Heart Association (NYHA) class II in 23 (6%); class III in 280 (72%); and class IV in 87 (22%) patients]. Mitral valve area increased from 0.6 +/- 0.4 to 2 +/- 0.7 cm2, mean transmitral gradients decreased from 26 +/- 8 to 5 +/- 3 mmHg and cardiac index improved from 2.2 +/- 0.8 to 3.0 +/- 0.7 l/min/m2 (P < 0.001). There were no procedure related deaths. An increase in mitral regurgitation by one grade was observed in 40 (10%) cases, with 8 (2%) cases developing severe mitral regurgitation. Oximetry evidence of left to right atrial shunt (Qp/Qs > or = 1.5:1) was observed in 11 (3%) patients. Four (1.0%) patients developed cardiac tamponade, none had thromboembolism. Follow-up of 290 cases at 26 +/- 5 weeks showed persistent improvement in clinical (NYHA class I in 98%) and echocardiographic mitral valve area. Percutaneous transvenous mitral commissurotomy is safe, easy to perform and provides excellent clinical and hemodynamic benefit in the majority of cases.

Comparative results of percutaneous balloon mitral valvuloplasty using the Trefoil/Bifoil and Inoue balloon techniques

This study compared the results in 150 consecutive patients with rheumatic mitral stenosis who underwent percutaneous balloon mitral valvuloplasty by means of a Trefoil/Bifoil balloon catheter (n = 100, Group 1) or the Inoue balloon catheter (n = 50, Group 2). There was significant improvement in mitral valve area after valvuloplasty in both groups: in Group 1 mitral valve area improved from 0.92 +/- 0.22 to 2.14 +/- 0.64 cm2 (P < 0.001) and in Group 2 from 1.0 +/- 0.26 to 2.06 +/- 0.59 cm2 (P < 0.001). There was no significant difference in the mitral valve area, mean diastolic gradient or mean left atrial pressure between Group 1 and Group 2 patients after valvuloplasty. There was a higher complication rate in Group 1 patients but this was largely related to our early learning experience with the procedure. The Trefoil/Bifoil catheter technique is more complex and involved a longer screening time: Group 1 (39 +/- 15 min) vs. Group 2 (22 +/- 10 min); P < 0.001. The cost of the Inoue balloon technique, however, was almost twice that of the Trefoil/Bifoil technique. This may have important implications for developing countries with limited health care budgets and a high prevalence of rheumatic heart disease.

Percutaneous balloon mitral valvuloplasty: comparison of double and single (Inoue) balloon techniques

To assess relative merits of the double and single (Inoue) balloon techniques of percutaneous balloon mitral valvuloplasty for treating symptomatic mitral stenosis, 33 patients who underwent dilatation with the double balloon were compared retrospectively with 28 who underwent dilatation with the Inoue balloon. There were no baseline differences in mean left atrial pressure, mean mitral gradient, or calculated mitral valve area between the two groups. The procedure was successful in 89% of patients in the double balloon group and in 93% in the Inoue balloon group. Final mitral valve area and absolute increase in mitral valve area were significantly greater in the double balloon group, in which there was a nonsignificant trend toward greater incidence of acute complications. Final left atrial pressure and mitral gradient were not different. Both techniques are useful and safe.

Mitral restenosis and mitral regurgitation 1 year after Inoue mitral balloon valvotomy in a population of patients with pliable mitral valve stenosis

To determine the rate of mitral restenosis and mitral regurgitation increase 1 year after mitral valvotomy using the Inoue balloon catheter, 66 consecutive patients with severe, pliable mitral stenosis had their mitral valve area (MVA) calculated by two-dimensional echocardiography (2DE) and Doppler before, immediately after balloon valvotomy, and at 1-year follow-up. Color Doppler studies were also done to detect small atrial septal defects (ASDs) and mitral regurgitation. The mean age of the patients was 31 +/- 12 years. Three patients were in New York Heart Association (NYHA) class II and 63 patients were in NYHA class III to IV. Sixty-two of the 66 patients had an echo score (Boston) of < or = 8. After Inoue balloon valvotomy (IBV), the MVA (2DE) increased from 0.8 +/- 0.2 to 1.9 +/- 0.3 cm2 (p < 0.001), and the Doppler MVA increased from 0.8 +/- 0.2 to 1.8 +/- 0.3 cm2 (p < 0.001). We detected 4 of 66 cases (6%) with significant residual mitral stenosis (MVA < 1.5 cm2). Mitral regurgitation increased in 14 of 66 patients (21%), but no patient developed severe mitral regurgitation. Fourteen out of 66 patients (20%) had ASDs that were detected on color Doppler. At 1-year follow-up the mean Doppler MVA was maintained at 1.8 +/- 0.4 cm2, with 6 of 66 patients (9%) exhibiting significant mitral valve restenosis. Residual significant mitral stenosis must be differentiated from mitral restenosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous mitral valvotomy using Inoue and double balloon technique: comparison of clinical and hemodynamic short term results in 350 cases

The results of percutaneous mitral valvotomy (PMV) by double balloon (N = 230, Group I) and Inoue single balloon (N = 120, Group II) technique were compared. The groups were similar with respect to baseline characteristics. Following PMV there were marked symptomatic and haemodynamic benefits in both the groups. There was significant increase in mitral valve area (MVA) estimated by Gorlin's equation (Group I: from 0.83 +/- 0.18 cm2 to 2.10 +/- 0.45 cm2, p < 0.001; Group II: from 0.83 +/- 0.17 cm2 to 2.16 +/- 0.39 cm2, p < 0.001) and by echoplanimetry (Group I: from 0.84 +/- 0.18 cm2 to 1.91 +/- 0.35 cm2, p < 0.001; Group II: from 0.88 +/- 0.17 cm2 to 1.96 +/- 0.30 cm2, p < 0.001). However, the percentage increase in MVA in the two groups by echoplanimetry (Group I: 136 +/- 59; Group II: 130 +/- 51; p = NS) and by Gorlin's equation (Group I: 164 +/- 69; Group II: 168 +/- 61; p = NS) were not statistically significant. Results were considered optimal when increase in MVA was > or = 1.5 cm2, percentage increase was > or = 50, and mitral regurgitation was < 2/4. Out of 216 patients in Group I where PMV could be performed, optimal results were achieved in 184 (85.2%) by Gorlin's equation and 178 (82.4%) by echoplanimetry. In Group II, out of 116 patients, optimal results were achieved in 107 (92.2%) by Gorlin's equation and 103 (89%) by echoplanimetry. Incidence of mitral regurgitation although higher in Group II (24.1% vs. 18.9%) was not statistically significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Balloon mitral valvotomy by using the Twin-AT catheter: immediate results and complications in 110 patients

Balloon mitral valvotomy, using a new Twin AT catheter (two balloons attached side by side over one shaft), was performed in 110 consecutive cases. The age of the patients ranged from 19-78 yr (mean 46 +/- 15). From a total of 94 females and 16 males, 23 of the patients (22%) had mitral valve calcification, 47 patients (46%) had atrial fibrillation, and 39 patients (37%) had mitral regurgitation (< +2). Twenty patients (18%) presented with restenosis following surgical commissurotomy. Total catheterization time was 101 +/- 26 min and the duration of the valvotomy procedure was 37 +/- 21 min in these cases. For the entire population, there was a significant reduction in mitral valve gradient (15 +/- 6 to 4.8 +/- 2.6 mmHg, p < .001), an increase in mitral valve area (MVA) (1.1 +/- 0.3 to 2.35 +/- 0.7 cm2, p < .001), and a decrease in mean pulmonary arterial pressure (31 +/- 12 to 26 +/- 11, p < .002) after the balloon mitral valvotomy. Sixteen patients (14%) developed significant left to right shunt, and in 22 patients (20%) mitral regurgitation increased moderately but without resulting in emergency valve replacement. There was one incidence of embolic episode and one pericardial tamponade. Adequate hemodynamic results (MVA > 1.5 cm2 and % increase in MVA > or = 50%) without major complications were obtained in 99 cases. In 9 patients with severely diseased valve (2 previous commissurotomy, one restenosis after balloon valvotomy), or small left ventricular cavity, insufficient results were obtained by the Twin-AT catheter.(ABSTRACT TRUNCATED AT 250 WORDS)

Balloon valvotomy for pregnant patients with severe pliable mitral stenosis using the Inoue technique with total abdominal and pelvic shielding

Balloon valvotomy by means of the Inoue technique was attempted in seven pregnant (5 to 9 months) patients with severe mitral stenosis; the mean age of the patients was 32 +/- 8 years, and all had a two-dimensional echocardiographic mitral valve score of < 8. Indications for Inoue balloon valvotomy included severe symptomatic mitral stenosis with a Doppler mitral valve area < or = 1 cm2 and heart failure refractory to medical therapy, or absolute contraindications for the use of beta-blockade; Inoue valvotomy was also indicated for patients who lived a long distance from the hospital. Inoue balloon valvotomy was performed with no angiography and total pelvic and abdominal shielding; the balloon catheter was introduced into the right atrium without the aid of fluoroscopy, which was used for the transseptal puncture. Stepwise two-dimensional echocardiographic Doppler mitral valve dilatation was done. After Inoue balloon valvotomy the mean Doppler mitral valve area increased from 0.8 +/- 0.1 to 2.0 +/- 0.3 cm2 (p < 0.01) and by two-dimensional echocardiography from 0.8 +/- 0.2 to 1.9 +/- 0.3 cm2 (p < 0.01), with no significant Doppler residual stenosis (defined as mitral valve area < or = 1.5 cm2). The mean total fluoroscopy time was 16 +/- 7 minutes. The degree of mitral regurgitation increased in two patients from grade 1+/4+ to grade 2+/4+ and from grade 0+/4+ to grade 2+/4+, respectively. There was no mortality or significant morbidity. Pregnancy was uneventful in all patients, and all were delivered of normal babies without complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term results of percutaneous mitral valvuloplasty with the Inoue balloon catheter

The initial 85 patients who successfully underwent percutaneous mitral valvuloplasty (PMV) with the Inoue balloon catheter at the Guangdong Cardiovascular Institute between November 1985 and November 1988 had a mean follow-up period of 5 +/- 1 year (range 43 to 79 months). Before and after PMV and at follow-up, mean diastolic mitral gradients by the catheter method were 17.5 +/- 6.2, 3.1 +/- 3.3 and 3.3 +/- 3.4 mm Hg, respectively (p < 0.001 before vs after PMV and before vs follow-up; and p > 0.05 after PMV vs follow-up). Mean diastolic mitral gradients by the Doppler method were 18 +/- 6, 8 +/- 5 and 9 +/- 5 mm Hg, respectively (p < 0.001 before vs after PMV and before vs follow-up; and p > 0.05 after PMV vs follow-up). Mean diastolic mitral gradients by the Doppler method were 18 +/- 6, 8 +/- 5 and 9 +/- 5 mm Hg, respectively (p < 0.001 before vs after PMV and before vs follow-up; and p > 0.05 after PMV vs follow-up). Mitral valve areas by the echo-Doppler method were 1.1 +/- 0.3, 2.0 +/- 0.4 and 1.8 +/- 0.5 cm2, respectively (p < 0.001 before vs after PMV and before vs follow-up; and p > 0.05 after PMV vs follow-up). Phonocardiographic and vectorcardiographic studies, and cardiopulmonary exercise testing showed significant improvement after PMV and at follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison between single (Inoue) and double balloon mitral valvuloplasty: immediate and short-term results

This study compared the results in 60 consecutive patients with severe rheumatic mitral stenosis, who underwent percutaneous double-balloon mitral valvuloplasty by means of a combination of 20 mm + 20 mm diameter balloon catheters (group A), with a similar group of 60 consecutive patients who underwent single (Inoue) balloon mitral valvuloplasty (group B). After balloon mitral valvuloplasty the hemodynamic measurements showed significant improvement in both groups: in groups A and B, respectively, mitral valve area calculated with the Gorlin formula increased from 0.9 +/- 0.2 to 2.1 +/- 0.5 cm2 (p less than 0.001) and from 0.8 +/- 0.2 to 1.9 +/- 0.4 cm2 (p less than 0.001). There was a significant improvement in cardiac functional status in both groups. There was no significant difference between the groups with regard to clinical or hemodynamic improvement, technical failure rate, inadequacy of dilatation, or complications. However, the double-balloon technique was more complex and involved a longer screening time--group A, 40 +/- 12 minutes; group B, 21 +/- 10 minutes (p less than 0.001). In our institution the disposable supplies used for the Inoue balloon technique were 40% more expensive than those used for the double-balloon technique.