Percutaneous mitral balloon valvotomy for recurrent mitral stenosis after surgical commissurotomy

Imaging in mitral stenosis: assessment before, during and after percutaneous balloon mitral valvuloplasty

Detailed assessment of mitral valve morphology is required to select patients for successful percutaneous balloon mitral valvuloplasty (PBMV). The mitral valve is routinely imaged using transthoracic and transesophageal echocardiography, which have more recently been supplemented with magnetic resonance imaging, 3D echocardiography and intracardiac echocardiography. The scope of PBMV is expanding and it is increasingly used for patients previously considered to have unfavorable mitral morphology. Here we review the evidence to support the examination of each component of the mitral valve and its surrounding structures and the advantages of each imaging modality. Appropriate echocardiographic views are recommended and periprocedural and postprocedural imaging techniques are discussed.

Patient profile and results of percutaneous transvenous mitral commissurotomy in mitral restenosis following prior percutaneous transvenous mitral commissurotomy vs surgical commissurotomy

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.

Immediate and long-term results following balloon mitral valvotomy in patients with atrial fibrillation

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.

Percutaneous Mitral Balloon Valvuloplasty for Patients with Rheumatic Mitral Stenosis

Percutaneous balloon dilatation of stenotic cardiac valves is used for the treatment of pulmonic, mitral, aortic, and tricuspid stenosis. Percutaneous mitral balloon valvuloplasty (PMV) has been used successfully as an alternative to open or closed surgical mitral commissurotomy in the treatment of symptomatic rheumatic mitral stenosis. PMV produces good immediate hemodynamic outcome, low complication rates, and clinical improvement in the majority of patients. PMV is safe and effective and provides clinical and hemodynamic improvement in rheumatic mitral stenosis. PMV is the preferred form of therapy for relief of mitral stenosis for a selected group of patients with symptomatic mitral stenosis.

Percutaneous valvuloplasty for mitral valve restenosis: postballoon valvotomy patients fare better than postsurgical closed valvotomy patients

AIM

To compare the results of percutaneous mitral valvuloplasty (BMV) for mitral restenosis in post-BMV versus postclosed mitral valvotomy (CMV) patients.

METHODS AND RESULTS

Ninety-two patients who underwent BMV for mitral restenosis were followed up prospectively. Of these, 28 patients had undergone previous percutaneous mitral valvuloplasty (PRIOR BMV) and 64 patients had undergone previous closed mitral valvotomy (PRIOR CMV). BMV for mitral restenosis was a success in 59% patients (57.1% PRIOR BMV, 59.3% PRIOR CMV, P = 1.0). Incidence of severe mitral regurgitation was 3.25%, all in the PRIOR CMV group. In univariate analysis, the major predictor of successful BMV for mitral restenosis was Wilkins score (P = 0.004). At a follow up of 3.47 + 2.07 years, mitral valve area was similar between groups (1.45 +/- 0.22, 1.46 +/- 0.26, P = 0.35). The combined end points of mitral valve replacement (MVR), need for re-repeat BMV for mitral restenosis or death was higher in the PRIOR CMV group (31.2% PRIOR CMV, 7.1% PRIOR BMV, P = 0.027). Event-free survival at follow up was lower in the PRIOR CMV group (69% PRIOR CMV, 92.8% PRIOR BMV) mainly due to the higher need for MVR (11 vs. 0 patients, P = 0.03).

CONCLUSIONS

In conclusion, following BMV for mitral restenosis, patients with PRIOR BMV are found to have lesser event rates on follow-up compared to patients with PRIOR CMV, though procedural success rates are similar.

Mitral balloon valvuloplasty

Percutaneous mitral balloon valvuloplasty (MBV) was introduced in 1984 by Inoue who developed the procedure as a logical extension of surgical closed commissurotomy. Since then, MBV has emerged as the treatment of choice for severe pliable rheumatic mitral stenosis (MS). With increasing experience and better selection of patient, the immediate results of the procedure have improved and the rate of complications declined. When the reported complications of MBV are viewed in aggregate, complications occur at approximately the following rates: mortality (0-0.5%), cerebral accident (1-2%), mitral regurgitation (MR) requiring surgery (1.6-3%). These complication rates compare favorably to those reported after surgical commissurotomy. Several randomized trials reported similar hemodynamic results with MBV and surgical commissurotomy. Restenosis after MBV ranges from 4% to 70% depending on the patient selection, valve morphology, and duration of follow-up. Restenosis was encountered in 31% of the author's series at mean follow-up 9 ± 5.2 years (range 1.5-19 years) and the 10, 15, and 19 years restenosis-free survival rates were (78 ± 2%) (52 ± 3%) and (26 ± 4%), respectively, and were significantly higher for patients with favorable mitral morphology (MES ⩽ 8) at 88 ± 2%, 67 ± 4% and 40 ± 6%), respectively (P < 0.0001). The 10, 15, and 19 years event-free survival rates were (88 ± 2%, 60 ± 4% and 28 ± 7%, respectively, and were significantly higher for patients with favorable mitral morphology (92 ± 2%, 70 ± 4% and 42 ± 7%, respectively (P < 0.0001). The effect of MBV on severe pulmonary hypertension, concomitant severe tricuspid regurgitation, left ventricular function, left atrial size, and atrial fibrillation are addressed in this review. In addition, the application of MBV in specific clinical situations such as in children, during pregnancy and for restenosis is discussed.

Percutaneous transvenous mitral commissurotomy versus surgical commissurotomy in the treatment of mitral stenosis

There is no doubt that percutaneous transvenous mitral commissurotomy (PTMC) in experienced centers is associated with a low risk of major complications and yields excellent immediate and long-term outcome. Although previous observational studies on both PTMC and surgical commissurotomy have indicated similar outcome between the two treatment strategies in terms of valve area improvement and risk of major complication (death, thromboembolism and significant resultant mitral regurgitation), it was not until recently that several prospective randomized trials comparing the two procedures and involving > 470 patients with favorable valve characteristics (pliable, noncalcified valve with mild subvalvular disease and no or mild mitral regurgitation), have confirmed that PTMC is indeed just as, if not more, effective as surgical commissurotomy. The late restenosis rate at up to 3-year follow-up appears comparable. Furthermore, PTMC has other additional benefits. It is nontraumatic, may be repeated without additional risk, and has been shown to be an extremely useful and efficacious palliative tool in those with end-stage mitral stenosis or with unfavorable valve anatomy who refuse surgery, and in certain subset of patients at high surgical risk because of medical comorbidities.

Percutaneous mitral balloon valvotomy

Percutaneous mitral balloon valvotomy (PMBV) was introduced in 1984 by Inoue who developed the procedure as a logical extension of surgical closed commissurotomy. Since then, PMBV has emerged as the treatment of choice for severe pliable rheumatic mitral stenosis (MS). With increasing experience and better selection of patient, the immediate results of the procedure have improved and the rate of complications declined. When the reported complications of PMBV are viewed in aggregate, complications occur at approximately the following rates: mortality (0-0.5%), cerebral accident (0.5-1%), mitral regurgitation (MR) requiring surgery (1.6-3%). These complication rates compare favorably to those reported after surgical commissurotomy. Several randomized trials reported similar hemodynamic results with PMBV and surgical commissurotomy. Restenosis after PMBV ranges from 4 to 70% depending on the patient selection, valve morphology, and duration of follow up. Restenosis was encountered in 21% of the author's series at mean follow-up 6 +/- 4.5 years and the 10 and 15 years restenosis-free survival rates were (70 +/- 3)% and (44 +/- 5)%, respectively, and were significantly higher for patients with favorable mitral morphology (85 +/- 3% and 65 +/- 6%), respectively (P < 0.0001). The 10 and 15 years event-free survival rates were (79 +/- 2)% and (43 +/- 9)% and were significantly higher for patients with favorable mitral morphology (88 +/- 2)% and (66 +/- 6)%, respectively (P < 0.0001). The effect of PMBV on severe pulmonary hypertension, concomitant severe tricuspid regurgitation, left ventricular function, left atrial size, and atrial fibrillation are addressed in this review. In addition, the application of PMBV in specific clinical situations such as in children, during pregnancy and for restenosis is discussed.

Immediate and long-term results of mitral balloon valvotomy for restenosis following previous surgical or balloon mitral commissurotomy

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.

Feasibility, safety, and morphologic predictors of outcome of repeat percutaneous balloon mitral commissurotomy

Early and mid-term results of repeat percutaneous balloon mitral commissurotomy (PBMC) were analyzed in 35 patients with symptomatic valvular restenosis: 12 patients (34%) after first successful PBMC and 23 patients (66%) after successful surgical closed mitral commissurotomy. Twenty-one patients had bilateral fused commissures, and 14 patients had unilateral or bilateral split commissures. Mitral valve area gain was significantly greater in the group with fused commissures compared with the group with split commissures (0.6 +/- 0.2 vs 0.3 +/- 0.2 cm(2), respectively, p = 0.04).

Effectiveness of percutaneous mechanical mitral commissurotomy using the metallic commissurotome in patients with restenosis after balloon or previous surgical commissurotomy

Balloon mitral valvuloplasty has been reported to give equal or less positive results after previous commissurotomy than after a first procedure. Percutaneous mechanical mitral commissurotomy (PMMC) is a new technique that has not yet been evaluated in this subset of patients. Of 1,175 PMMC procedures (1,175 patients), 173 patients (14.7%) had previous commissurotomy; patients were older (40 vs 35 years of age, p <0.0001) and more often in atrial fibrillation (34% vs 21%, p = 0.0016) than were patients who had not undergone previous commissurotomy. The baseline transmitral gradient was lower (17 +/- 8 vs 19 +/- 8 mm Hg, p <0.002) and the echocardiographic Wilkins score was higher (8.7 +/- 1.9 vs 7.6 +/- 1.8, p <0.0001) for patients who underwent previous commissurotomy. Baseline mitral valve area was comparable between the 2 groups (0.96 +/- 0.21 vs 0.93 +/- 0.24 cm(2)). Immediate results were satisfactory, although slightly less favorable after previous commissurotomy, with a final mitral valve area of 2.01 +/- 0.30 versus 2.12 +/- 0.36 cm(2) (p <0.0001), and a residual transvalvular gradient of 5.0 +/- 3.6 versus 4.2 +/- 4.1 mm Hg (p = 0.003). The rates of procedural success (93%) and severe complications (4.7%) were comparable between the 2 groups. Thus, PMMC is an effective and safe technique for the treatment of mitral restenosis after previous commissurotomy.

Percutaneous mitral balloon valvuloplasty in pregnant women with mitral stenosis

Forty-four consecutive pregnant patients with mitral stenosis were submitted to percutaneous mitral valvuloplasty (PMV) over a period of 12 years. The mean age was 28 +/- 6 years and the mean gestational age was 23 +/- 6 weeks. The mean mitral valve area had a significant increase from 1.17 +/- 0.26 to 2.06 +/- 0.41 cm(2) (P = 0.0000). The mean mitral valve gradient decreased from 16.22 +/- 5.55 to 7.94 +/- 3.75 mm Hg (P = 0.0001). The procedure was performed successfully in 95% of the patients and there were no major complications. Concerning labor and delivery, we evaluated 37 patients. Thirty patients (81%) reached term and delivered normal infants. Seven patients (18.9%) delivered prematurely, resulting in two fetal death; one patient delivered a stillborn. We concluded that PMV is a safe procedure for the treatment of mitral stenosis in pregnant patients, providing significant symptomatic relief and better clinical conditions for labor and delivery.

Percutaneous transvenous mitral commissurotomy: immediate and long-term follow-up results

Percutaneous transvenous mitral commissurotomy has emerged as an effective nonsurgical technique for the treatment of patients with symptomatic mitral stenosis. This report highlights the immediate and long-term follow-up results of this procedure in an unselected cohort of patients with rheumatic mitral stenosis from a single center. It was performed in a total of 4,850 patients using double balloon in 320 (6.6%), flow-guided Inoue balloon technique in 4,374 (90.2%), and metallic valvulotome in 156 (3.2%) patients. Their age range was 6.5-72 years (mean, 27.2 +/- 11.2 years) and 1,552 (32%) patients were under 20 years of age. Atrial fibrillation was present in 702 (14.5%) patients. No patient was rejected on the basis of echocardiographic score using the Wilkins criteria. Echocardiographic score of > or = 8 was present in 1,632 (33.6%) patients, of which 103 (2.1%) had densely calcified (Wilkins score 4+) valve. A detailed clinical and echocardiographic (two-dimensional, continuous-wave Doppler and color-flow imaging) assessment was done at every 3 months for the first year and at 6-month interval thereafter. The procedure was technically successful in 4,838 (99.8%) patients but optimal result was achieved in 4,408 (90.9%) patients with an increase in mitral valve area (MVA) from 0.7 +/- 0.2 to 1.9 +/- 0.3 cm(2) (P < 0.001) and a reduction in mean transmitral gradient from 29.5 +/- 7.0 to 5.9 +/- 2.1 mm Hg (P < 0.001). The mean left atrial pressure decreased from 32.1 +/- 9.8 to 13.1 +/- 6.2 mm Hg (P < 0.001). Although there was no statistically significant difference in the MVA achieved between de novo and restenosed valves (1.9 +/- 0.3 and 1.8 +/- 0.2 cm(2), respectively; P > 0.05), or between noncalcific and calcific valves (2.0 +/- 0.3 and 1.8 +/- 0.2 cm(2), respectively; P > 0.05), on the whole MVA obtained after percutaneous transvenous mitral commissurotomy was less in restenosed and calcific valves. Ten (0.20%) patients had cardiac tamponade during the procedure. Mitral regurgitation appeared or worsened in 2,038 (42%) patients, of which 68 (1.4%) developed severe mitral regurgitation. Urgent mitral valve replacement was carried out in 52 (1.1%) of these patients. Data of 3,500 patients followed over a period of 94 +/- 41 months (range, 12-166 months) revealed MVA of 1.7 +/- 0.3 cm(2). Elective mitral valve replacement was done in 34 (0.97%) patients. Mitral restenosis was seen in 168 (4.8%) patients, of which 133 (3.8%) were having recurrence of class III or more symptoms. Thus, percutaneous transvenous mitral commissurotomy is an effective and safe procedure with gratifying results in high percentage of patients. The benefits are sustained in a majority of these patients on long-term follow-up. It should be considered as the treatment of choice in patients with rheumatic mitral stenosis of all age groups.

Which patients benefit from percutaneous mitral balloon valvuloplasty? Prevalvuloplasty and postvalvuloplasty variables that predict long-term outcome

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.

Percutaneous mitral commissurotomy for restenosis after surgical commissurotomy: late efficacy and implications for patient selection

OBJECTIVES

The results of percutaneous mitral commissurotomy were assessed in patients with restenosis after surgical commissurotomy.

BACKGROUND

Balloon dilation is feasible in patients with restenosis after surgical commissurotomy, but little is known about its late efficacy.

METHODS

We studied 232 patients who had undergone percutaneous mitral commissurotomy a mean of 16 +/- 8 years after surgical commissurotomy. Mean age was 47 +/- 14 years; 81 patients (35%) had valve calcification. All patients had restenosis with bilateral commissural fusion as assessed by echocardiography. Technical failure occurred in 9 patients and the procedure used a single balloon in 7 patients, a double balloon in 95, and the Inoue balloon in 121.

RESULTS

Complications were death in 1 patient (0.4%) and mitral regurgitation >2/4 in 10 (4%); 191 patients (82%) had good immediate results (valve area > or =1.5 cm2 without regurgitation >2/4). Predictors of poor immediate results in multivariate analysis were older age (p < 0.001), lower initial valve area (p = 0.01) and the use of the double-balloon technique (p = 0.015). In the 175 patients who underwent follow-up, 8-year survival without operation and in New York Heart Association class I or II was 48 +/- 5%, and 58 +/- 6% after good immediate results. In this latter group, poor late functional results were predicted by higher cardiothoracic index (p < 0.0001), previous open-heart commissurotomy (p = 0.05) and lower final valve area (p < 0.0001) in a multivariate Cox model.

CONCLUSIONS

Percutaneous mitral commissurotomy is safe and provides good immediate results in selected patients with restenosis after surgical commissurotomy. After good immediate results, the conditions of more than half of the patients remained improved at 8 years, enabling reoperation to be deferred.

Mitral balloon valvotomy for patients with mitral stenosis in atrial fibrillation: immediate and long-term results

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.

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.

Comparison of immediate and long-term outcome of percutaneous transvenous mitral commissurotomy in patients who have and have not undergone previous surgical commissurotomy

This study compared the immediate and long-term outcome of percutaneous transvenous mitral commissurotomy (PTMC) in patients who had (restenosis group, n = 9) or had not (de novo group, n = 27) previously undergone surgical mitral commissurotomy. The baseline echocardiographic score, which is an index of deformity of the mitral valve apparatus, was significantly higher in the restenosis group than in the de novo group (11 +/- 3 vs 7 +/- 2, p < 0.01), although age, left atrial diameter, and the prevalence of atrial fibrillation were similar. PTMC was performed by the Inoue technique, and was abandoned in 1 patient from the restenosis group because of failed trans-septal puncture. Including this patient, 3 patients (33%) in the restenosis group had a thickened atrial septum compared with only 1 (4%) in the de novo group. One patient in the de novo group developed cardiac tamponade during this procedure. In both groups, the mitral valve area increased significantly, but the success rate of PTMC was lower in the restenosis group (4/9 patients, 44%) than in the de novo group (22/27 patients, 81%) (p < 0.05). Twenty-six patients who had successful PTMC were followed up over 51 +/- 14 months. After 4 years of follow-up. 3 out of 4 patients (75%) in the restenosis group and 3 out of 22 patients (14%) in the de novo group demonstrated echocardiographic restenosis (p < 0.01). Stepwise multivariate analysis revealed that the echocardiographic score was the only significant predictor of both the immediate and long-term outcome. In conclusion, the immediate and long-term outcome of PTMC were worse in patients who had undergone previous surgical mitral commissurotomy than in those who had not. This was mainly attributable to the difference in the severity of the valvular lesions. In addition, our data suggested that a thickened atrial septum, possibly related to surgery as well as chronic rheumatic disease, may affect the performance of PTMC.

Immediate results of percutaneous mitral commissurotomy. A predictive model on a series of 1514 patients

BACKGROUND

The wide use of percutaneous mitral commissurotomy (PMC) underlines the need to identify the predictive factors of the results. Using a large series allowed us to develop a multivariate model that can be applied to improve patient selection.

METHODS AND RESULTS

Between 1986 and 1995. PMC was undertaken in 1514 patients. Mean age was 45 +/- 15 years. Echocardiography showed that 245 patients (16%) had pliable valves and mild chordal thickening (group 1), 886 (59%) had extensive subvalvular disease (group 2), and 383 (25%) had calcified valves (group 3). PMC failed in 22 patients; it was performed with a single balloon in 30 patients, a double balloon in 586, and the Inoue balloon in 876. Good immediate results were defined as a valve area > or = 1.5 cm2 with mitral regurgitation Sellers' grade < or = 2 and were obtained in 1348 patients (89%). A logistic model developed from the first 1088 cases identified the following predictors of immediate results: age (P = .004), echocardiographic group (P < .0001), valve area (P < .0001), and effective balloon dilating area (EBDA) (P = .03). Two interactions were significant: age at previous commissurotomy (P = .013) and EBDA by initial mitral regurgitation (P = .034). The type of balloon was of borderline significance (P = .09). The model was validated on an independent sample comprising the subsequent 426 procedures. For a threshold of probability of good results of .75, sensitivity was 92%, specificity 25%, and predictive accuracy 87%.

CONCLUSIONS

Prediction of the immediate results of PMC is multifactorial. The predictive model developed and validated can be contributive in decision making for individual patients.