Feasibility of percutaneous mitral commissurotomy in patients with commissural mitral valve calcifications

Abstract

Background: Mitral valve calcifications, especially located in the commissural area, are often considered as a relative contra-indication to percutaneous mitral commissurotomy (PMC). We sought to evaluate in a large series of patients with mitral stenosis (MS), PMC results according to the degree and location of mitral valve calcifications. Methods: Over a 3 years period, all consecutive patients who underwent a PMC at our institution were enrolled in the present study. Calcifications were assessed using transthoracic echocardiography and defined as bright areas with echocardiographic shadowing. According to the distribution of calcifications (within the valves leaflets' or at the commissural level) and the degree of calcifications (independently scored for each commissure from 0 to 3, 0 = absent, 1 = mild, 2 = moderate, 3 = severe), 3 groups were defined: group 1 = patients without calcifications, group 2 = patients with leaflets' calcifications but no significant commissural calcifications and group 3 = patients with at least one calcified commissure of grade ≥2. Patients with severe bilateral calcifications were excluded from PMC. A good immediate PMC result was defined as a final valve area ≥1.5 cm2 with no mitral regurgitation >2/4. Results: We enrolled 464 patients. Patients in group 2 and 3 were older, presented more often in atrial fibrillation and with more severe MS than patients in group 1. PMC success rate decreased from group 1 to 3. However, a complete opening of at least one commissure was achieved similarly in the 3 groups and in group 3 the calcified commissure could be totally split in 40%. Conclusion: In this large series of patients with MS we showed that 1) a successful PMC is obtained less frequently in patients with calcified commissures but 2) a successful PMC can still be achieved in a large proportion of patients and 3) the calcified commissure can be split in more than one third of patients. Our results support the use of PMC as a first line treatment of patients with severe MS even in the presence of commissural calcifications if clinical characteristics are favorable.