Percutaneous transvenous mitral commissurotomy using an Inoue balloon in children with rheumatic mitral stenosis

The Modified History of Juvenile Rheumatic Mitral Stenosis Following Percutaneous Transmitral Commissurotomy: Intermediate-Term Outcomes From a Decadal Follow-Up Study

AIM

There are few studies that have looked at the long-term outcomes of juvenile mitral stenosis (JMS) following percutaneous transmitral commissurotomy (PTMC). This study sought to analyse the modified history of JMS in children following PTMC.

METHOD

We describe a longitudinal, observational follow-up study of all children and young adults aged <20 years who underwent PTMC at Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India from 2012 to 2021. Children were followed up for progression of mitral stenosis (MS), development of mitral regurgitation (MR), need for repeat interventions (percutaneous or surgical), and mortality.

RESULTS

A total of 114 children and adolescents underwent the procedure. The mean age of children in the study was 15.1±2.5 years. After immediate procedural success, there was a tendency towards restenosis with respect to valve areas and transmitral gradients at follow-up. Severe MR after the procedure was noted in 2.6%. Compliance with penicillin prophylaxis was noted in 42.5%. The Kaplan-Meier survival estimate over 10 years showed a mortality rate of 1.98/100 patient-years and a re-intervention rate (re-do PTMC or surgery) of 5.50/100 patient-years. Additional valvular lesions were noted in 13.1% of children during follow-up. Severe symptomatic status at presentation (New York Heart Association class 4) was predictive of mortality, and children aged <15 years often needed re-intervention.

CONCLUSIONS

With a mortality rate of 6.1% and re-do intervention rate of 15.8% during extended follow-up, JMS has considerable healthcare implications in terms of morbidity and mortality in children and young adults.

Pediatric cardiac interventions: Innovations from India

India, owing to its population structure, faces an enormous burden of children born with congenital heart disease (CHD). Systematic challenges such as limited public health infrastructure, a shortage of trained specialists, and high out-of-pocket expenditures hinder uniform access to comprehensive CHD care. Despite these limitations, Indian pediatric cardiologists have delivered innovative and often cost-effective solutions to challenging clinical problems. Indigenous devices such as the MyVal transcatheter heart valve, Konar-MF (multifunction) occluder, and Zephyr large-diameter stents are significant achievements in their respective fields. Static balloon dilatation of interatrial septum and balloon-assisted atrial septal defect (ASD) device implantation are prime examples of many innovations that were established by Indians and followed across the world. India also helped consolidate significant interventions in children, such as percutaneous transvenous mitral commissurotomy and interventions for aortoarteritis. Notably, Indian centers have published some of the largest series on transcatheter closure of sinus venosus ASD and ruptured sinus of Valsalva aneurysm. Close collaboration with adult coronary interventionalists has facilitated innovations borrowed from coronary chronic total occlusion hardware and techniques to recanalize ductus arteriosus or membranous-type pulmonary atresia. This manuscript discusses some of India's innovative contributions to the field of pediatric cardiac interventions.

Catheter interventions for mitral stenosis in children: results and perspectives

Stenosis of the mitral valve most often occurs as a result of chronic rheumatic heart disease, causing thickening and fibrosis of the mitral valve apparatus. Rheumatic heart disease continues to be a major public health problem in several developing countries and mitral stenosis is also common in these regions. According to the reports from India and Africa, the disease tends to follow a rapidly progressive course in children. The treatment of choice is balloon dilatation of the mitral valve. Echocardiography is indispensable for this procedure. Before planning the procedure, it is essential to assess the suitability of balloon dilatation. Echocardiography performed during the procedure helps to decide whether the size of the balloon needs to be increased in case of inadequate relief of stenosis. Most published series have reported an immediate success rate of over 90% with balloon dilatation in children and young adults. With an increase in mitral valve area and improvement in functional class, the left atrial pressure and the transmitral gradients fall. These gratifying results are also reported from very young children of less than 12 years of age. It is recommended to start with a smaller balloon size and increase its size in a stepwise fashion to minimize complications. The complications, seen in about 1% to 2% of cases, include development of significant mitral regurgitation and hemopericardium, secondary to cardiac chamber perforation. The long-term results indicate slightly higher restenosis rates in children than in adults. Most children with restenosis can undergo successful repeat dilatation.

Percutaneous transluminal mitral commissurotomy for rheumatic mitral stenosis in a 5-year-old child

We report a 5-year-old boy weighing 11 kg, with severe mitral valve stenosis of rheumatic aetiology, who underwent successful percutaneous transluminal mitral commissurotomy (PTMC) with valvuloplasty balloon. Postprocedural mean pressure gradient across the mitral valve decreased to 6 mmHg from an initially recorded value of 22 mmHg. In addition to symptomatic improvement, the mitral valvular area increased from 0.4 to 0.8 cm(2) without significant change in mitral regurgitation. At 1- and 3-month follow up, transthoracic echocardiography revealed further improvement with an increase in mitral valve area to 1.0 cm(2), a decrease in pulmonary arterial pressure, and a mean mitral valve pressure gradient of 8 mmHg with trivial mitral regurgitation. To best of our knowledge, this is the first successful PTMC procedure performed in the youngest and smallest ever reported child with rheumatic mitral stenosis (MS). We conclude that PTMC with valvuloplasty balloon could be a logical alternative to surgery in young patients with rheumatic MS.

Percutaneous transmitral commissurotomy in juvenile mitral stenosis—comparison of long term results of Inoue balloon technique and metallic commissurotomy

OBJECTIVES

To compare the immediate and long term results of percutaneous mitral valvotomy using metallic commissurotome and Inoue balloon in juvenile mitral stenosis.

BACKGROUND

Inoue balloon technique for mitral commissurotomy (IBMC) is well established and carried out worldwide in the treatment of juvenile mitral stenosis. Percutaneous mitral metallic commissurotomy (PMMC) is reported to be a cheaper and effective alternative to balloon mitral commissurotomy.

METHODS

Thirty-three patients aged less than 20 years, who underwent PMMC, were compared with 33 age and sex matched control patients who underwent IBMC. Success of valvotomy, procedure related complications, and follow-up events of the two techniques were compared.

RESULTS

Basal echocardiographic and hemodynamic data were similar in both groups. Procedural success was similar in both groups, 31/33. Complications like cardiac tamponade and mitral regurgitation (requiring or not requiring mitral valve replacement) were similar in both groups. On follow-up of more than 3 years, both groups had comparable hemodynamic parameters and restenosis rates.

CONCLUSIONS

Both IBMC and PMMC are successful in providing relief from severe juvenile mitral stenosis in terms of gain in valve area and reduction in transmitral gradient. Both techniques have similar procedural success and complication rates. The long term follow-up results are comparable at follow-up of more than 3 years.

Long term clinical and echocardiographic results of mitral balloon valvotomy in children and adolescents

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.

Comparison of percutaneous transmitral commissurotomy with Inoue balloon technique and metallic commissurotomy: immediate and short-term follow-up results of a randomized study

BACKGROUND

The Inoue balloon technique for mitral commissurotomy is well established and carried out worldwide. Metallic commissurotomy is reported to be a cheaper and effective alternative to balloon mitral commissurotomy.

METHODS

One hundred patients were randomized into 2 groups to undergo percutaneous transmitral commissurotomy (PTMC) by means of the Inoue balloon technique (IBMC, n = 49) or metallic commissurotomy (PMMC, n = 51). Patients were crossed over to the other technique when the initial technique was a failure. Success of valvotomy, procedure-related complications, and follow-up events of the 2 techniques were compared.

RESULTS

Basal echocardiographic and hemodynamic data were similar in both groups. Procedural success was similar in both groups: 45 of 49 procedures (91.8%) in the IBMC group, compared with 46 of 51 procedures (90.18%) in the PMMC group (P = 1.0). Crossover was also comparable, with 1 occurring in the IBMC group, compared with 3 in the PMMC group. Complications such as cardiac tamponade and mitral regurgitation (requiring or not requiring mitral valve replacement) were similar in both groups, with 3 complications in the IBMC group, compared with 4 complications in the PMMC group (P =.29). After a follow-up period of approximately 4 months, both groups had similar event rates and comparable hemodynamic parameters (P = not significant).

CONCLUSIONS

Both IBMC and PMMC are successful means of providing relief from severe mitral stenosis with a gain in valve area and reduction in transmitral gradient. Both techniques have similar procedural success, complication rates, and follow-up events.

Interventional cardiac catheterization

Over the past decade, transcatheter interventions have become increasingly important in the treatment of patients with congenital heart lesions. These procedures may be broadly grouped as dilations (e.g., septostomy, valvuloplasty, angioplasty, and endovascular stenting) or as closures (e.g., vascular embolization and device closure of defects). Balloon valvuloplasty has become the treatment of choice for patients in all age groups with simple valvar pulmonic stenosis and, although not curative, seems at least comparable to surgery for congenital aortic stenosis in newborns to young adults. Balloon angioplasty is successfully applied to a wide range of aortic, pulmonary artery, and venous stenoses. Stents are useful in dilating lesions of which the intrinsic elasticity results in vessel recoil after balloon dilation alone. Catheter-delivered coils are used to embolize a wide range of arterial, venous, and prosthetic vascular connections. Although some devices remain investigational, they have been successfully used for closure of many arterial ducts and atrial and ventricular septal defects. In the therapy for patients with complex CHD, best results may be achieved by combining cardiac surgery with interventional catheterization. The cooperation among interventional cardiologists and cardiac surgeons was highlighted in a report of an algorithm to manage patients with tetralogy of Fallot or pulmonary atresia with diminutive pulmonary arteries, involving balloon dilation, coil embolization of collaterals, and intraoperative stent placement. In this setting, well-planned catheterization procedures have an important role in reducing the overall number of procedures that patients may require over a lifetime, with improved outcomes.