Balloon mitral commissurotomy in juvenile rheumatic mitral stenosis: a ten-year clinical and echocardiographic actuarial results

Balloon Mitral Valvotomy With the Accura Double-Lumen Balloon Catheter: Immediate and One-Year Clinical Outcomes

Objective

Despite the decline in the incidence of rheumatic heart disease in developed countries, the disease still remains endemic among individuals of low socioeconomic status. The aim of the study is to assess immediate and one-year outcomes of balloon mitral valvotomy using the double-lumen Accura balloon (Vascular Innovations Co., Nonthaburi, Thailand) in patients with mitral valve stenosis.

Methods

This was a single-centre, observational, investigator-initiated retrospective study. All consecutive patients undergoing balloon mitral valvotomy with the Accura balloon between January 2015 and June 2020 were included. The primary endpoint was procedural success defined as an increase in mitral valve area (MVA) ≥50% from basal valve area or final valve area of ≥1.5 cm², in the absence of mitral regurgitation grade >2. Clinical, echocardiographic, and haemodynamic parameters were assessed at the one-year follow-up.

Results

A total of 62 patients underwent balloon mitral valvotomy. The mean age was 34.9 ± 8.0 years, and 54 (87.1%) patients were female. Mean Wilkins' echo score was 7.5 ± 0.5. Procedural success was achieved in 59 (96.7%) patients. Mean MVA increased from 0.75 ± 0.14 cm² to 1.64 ± 0.21 cm², and mean mitral valve gradient decreased from 24.9 ± 5.5 mmHg to 7.30 ± 1.40 mmHg. Atrial fibrillation, mitral valve replacement, and moderate to severe mitral regurgitation occurred in 36 (59.0%), two (3.3%), and two (3.3%) patients, respectively. No death, cerebrovascular accidents, restenosis, or redo procedures occurred.

Conclusion

Balloon mitral valvotomy using the double-lumen Accura balloon is safe in patients with mitral valve stenosis.

Contemporary Diagnosis and Management of Rheumatic Heart Disease: Implications for Closing the Gap: A Scientific Statement From the American Heart Association

The global burden of rheumatic heart disease continues to be significant although it is largely limited to poor and marginalized populations. In most endemic regions, affected patients present with heart failure. This statement will seek to examine the current state-of-the-art recommendations and to identify gaps in diagnosis and treatment globally that can inform strategies for reducing disease burden. Echocardiography screening based on World Heart Federation echocardiographic criteria holds promise to identify patients earlier, when prophylaxis is more likely to be effective; however, several important questions need to be answered before this can translate into public policy. Population-based registries effectively enable optimal care and secondary penicillin prophylaxis within available resources. Benzathine penicillin injections remain the cornerstone of secondary prevention. Challenges with penicillin procurement and concern with adverse reactions in patients with advanced disease remain important issues. Heart failure management, prevention, early diagnosis and treatment of endocarditis, oral anticoagulation for atrial fibrillation, and prosthetic valves are vital therapeutic adjuncts. Management of health of women with unoperated and operated rheumatic heart disease before, during, and after pregnancy is a significant challenge that requires a multidisciplinary team effort. Patients with isolated mitral stenosis often benefit from percutaneous balloon mitral valvuloplasty. Timely heart valve surgery can mitigate the progression to heart failure, disability, and death. Valve repair is preferable over replacement for rheumatic mitral regurgitation but is not available to the vast majority of patients in endemic regions. This body of work forms a foundation on which a companion document on advocacy for rheumatic heart disease has been developed. Ultimately, the combination of expanded treatment options, research, and advocacy built on existing knowledge and science provides the best opportunity to address the burden of rheumatic heart disease.

Meta-Analysis of the Incidence, Prevalence, and Correlates of Atrial Fibrillation in Rheumatic Heart Disease

Objective:

To estimate the incidence, prevalence, and correlates of atrial fibrillation (AF) in a global population with rheumatic heart disease (RHD).

Methods:

Bibliographic databases were searched to identify all published studies providing data on AF in patients with RHD. Random-effects meta-analysis method was used to pool estimates.

Results:

Eighty-three studies were included, reporting data from 75,637 participants with RHD in 42 countries. The global prevalence of AF in RHD was 32.8% (range: 4.3%–79.9%). It was higher in severe valvular disease (30.8% vs 20.7%, p = 0.009), in severe mitral valve disease compared to severe aortic disease (30.4% vs 6.3%, p = 0.038). The global cumulative incidence of AF in patients with RHD was 4.8%, 11.4%, 13.2%, and 30.8% at 1, 2, 5, and 10 years of follow-up, respectively. From comparison between patients with and without AF, AF was associated with increased age (mean difference [MD]: 9.5 years; 95% CI: 7.8–1.3), advanced heart failure (odds ratio [OR]: 4.4; 95% CI 2.1–9.3), tricuspid valve involvement (OR: 4.0; 95% CI: 3.0–5.3), history of thromboembolism (OR: 6.2; 95% CI: 3.4–11.4), highly sensitive C-reactive protein (MD: 5.5 mg/dL; 95% CI: 1.2–9.8), systolic pulmonary arterial pressure (MD: 3.6 mmHg; 95% CI: 0.8–6.3), right atrium pressure (MD: 1.5 mmHg; 95% CI: 1.0–2.0), and left atrium diameter (MD: 8.1 mm; 95% CI: 5.5–10.7).

Conclusions:

About one-third of patients with RHD have AF, with an incidence which almost triples every five years after diagnosis. Factors associated with AF include age, advanced heart failure, thromboembolism, and few cardiac hemodynamics parameters.

Percutaneous transvenous mitral commissurotomy in juvenile mitral stenosis

BACKGROUND

Percutaneous transvenous mitral commissurotomy (PTMC) is a valid alternative to surgical therapy in selected patients with mitral stenosis. Juvenile mitral stenosis (JMS) varies uniquely from adult rheumatic heart disease (RHD). We aimed to evaluate the efficacy of PTMC in JMS patients.

METHODS

It was a single centre, retrospective study conducted between July 2013 to June 2015 in Shahid Gangalal National Heart Centre, Kathmandu, Nepal. Medical records of all consecutive patients aged less than 21 years who underwent PTMC were included. Mitral valve area (MVA), left atrial pressure and mitral regurgitation (MR) were compared pre and post procedure.

RESULTS

During the study period 131 JMS patients underwent PTMC. Seventy (53.4%) were female and 61 (46.6%) were male. Among the 131 patients, 40 (30.5%) patients were below the age of 15 years. Patient age ranged between 9 to 20 years with the mean of 16.3±2.9 years. Electrocardiography (ECG) findings were normal sinus rhythm in 115 (87.7%) patients and atrial fibrillation in 16 (12.3%) patients. Left atrial size ranged from 2.9 to 6.1 cm with the mean of 4.5±0.6 cm. The mean MVA increased from 0.8±0.1 cm(2) to 1.6±0.2 following PTMC. Mean left atrial pressure decreased from their pre-PTMC state of 27.5±8.6 to 14.1±5.8 mmHg. Successful results were observed in 115 (87.7%) patients. Suboptimal MVA <1.5 cm(2) in 11 (8.4%) patients and post-procedure MR of more than moderate MR in 5 (3.8%) patients was the reason for unsuccessful PTMC.

CONCLUSIONS

PTMC in JMS is safe and effective.

Balloon mitral valvotomy in youngest documented rheumatic mitral stenosis patient

Juvenile rheumatic mitral stenosis (MS) is common in the Indian subcontinent. Early recognition and management is essential. Rarely rheumatic MS may occur in <5 years of age, wherein rapid hemodynamic progression and cardiac morbidity and mortality occurs. Severe/symptomatic MS in preschool age requires urgent and meticulous decision making. Condition of valve and wishes of parents may complicate management decisions. Percutaneous transmitral commissurotomy (PTMC) may, therefore, become the only life-saving intervention in these cases unless contraindicated, although the procedure entails considerable technical issues in this age group. Herein, we report a successful balloon mitral valvotomy in a 4-year-old child with severe rheumatic MS (documented since 2 years 6 months of age) presenting with repeated pulmonary edema. To the best of our knowledge, this child is the youngest documented case of established rheumatic heart disease and also one of the youngest PTMC procedure performed. This report supports the clinical usefulness of PTMC in childhood MS; however, pertinent technical issues are raised, which needs a proper consensus.

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.

A review of valve surgery for rheumatic heart disease in Australia

BACKGROUND

Globally, rheumatic heart disease (RHD) remains an important cause of heart disease. In Australia it particularly affects older non-Indigenous Australians and Aboriginal Australians and/or Torres Strait Islander peoples. Factors associated with the choice of treatment for advanced RHD remain variable and poorly understood.

METHODS

The Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database was analysed. Demographics, co-morbidities, pre-operative status and valve(s) affected were collated and associations with management assessed.

RESULTS

Surgical management of 1384 RHD and 15843 non-RHD valve procedures was analysed. RHD patients were younger, more likely to be female and Indigenous Australian, to have atrial fibrillation (AF) and previous percutaneous balloon valvuloplasty (PBV). Surgery was performed on one valve in 64.5%, two valves in 30.0% and three valves in 5.5%. Factors associated with receipt of mechanical valves in RHD were AF (OR 2.69) and previous PBV (OR 1.98) and valve surgery (OR 3.12). Predictors of valve repair included being Indigenous (OR 3.84) and having fewer valves requiring surgery (OR 0.10). Overall there was a significant increase in the use of mitral bioprosthetic valves over time.

CONCLUSIONS

RHD valve surgery is more common in young, female and Indigenous patients. The use of bioprosthetic valves in RHD is increasing. Given many patients are female and younger, the choice of valve surgery and need for anticoagulation has implications for future management of RHD and related morbidity, pregnancy and lifestyle plans.

Heart failure in children in tropical regions

With the ever increasing younger population in tropical countries, the number of children with heart failure is increasing. However, the etiology of heart failure in this region varies considerably from that in the temperate region, with infectious causes leading the list. In this review, we have summarized the important causes of heart failure seen in the pediatric population in tropical regions.

Mitral stenosis

Mitral stenosis is a common disease that causes substantial morbidity worldwide. The disease is most prevalent in developing countries, but is increasingly being identified in an atypical form in developed countries. All treatments that increase valve area improve morbidity. Mortality improves with surgery; the benefit of percutaneous balloon valvuloplasty to mortality might be similar to that of surgery but needs further study. Percutaneous balloon valvuloplasty is the treatment of choice for patients in whom treatment is indicated, except for those with suboptimum valve morphology, and even these patients are sometimes treated with this procedure if surgery is not feasible or if surgical risk is prohibitive. We review the pathology, diagnosis, and treatment options for patients with mitral stenosis.

Relation of patient age to outcome of percutaneous mitral valvuloplasty

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.

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.