Impact of commissural calcification on the immediate result of percutaneous mitral commissurotomy

Abstract

Percutaneous mitral commissurotomy (PMC) is the treatment of choice of clinically significant rheumatic mitral stenosis with favourable anatomy. However, its indications may be extended to less favourable cases. To determine whether the presence of calcium in the mitral valve commissures influences the immediate result of PMC. PMC by the Inoue balloon was attempted in 247 patients (mean age: 35 years) with severe MS. All the patients had undergone echocardiographic examination before PMC to assess mitral anatomy, commissural calcification (CC) and to determine the Wilkins score. According to the absence or presence of CC, patients were divided into 2 groups: 216 patients in group CC− (no commissural calcification) and 31 patients in group CC+ (presence of calcification in 1 or 2 commissures). Baseline mitral valve area (MVA) was 1 ± 0.19 cm2 (range: 0.5–1.4 cm2), the mean value of Wilkins score was 7.98 ± 1.61 (range: 5–13) and 29 patients had unilateral commissural calcification. Post-PMC success was defined as final MVA ≥ 1.5 cm2 and no mitral regurgitation ≥ grade 3. After PMC, the mean MVA increased to 1.79 ± 0.34 cm2 (P < 0.001) resulting in a success rate of 83%. Severe mitral regurgitation (MR) occurred in 5 patients (2%). Final MVA (1.83 ± 0.32 cm2 versus 1.50 ± 0.36 cm2), success rate (87% versus 55%) and the rate of opening of at least one commissure (97% versus 77%) were significantly different between groups CC− and CC+ (P < 0.001). The rate of post-PMC MR of grade ≥ 3 was not different between the two groups (2% in group CC− and 0% in group CC+; P = 0.6). Our results showed that the presence of commissural calcification was associated with a lower procedural success rate, but a good immediate result could be achieved in half of cases. Then, unilateral commissural calcification should not be considered as a contraindication to PMC.