Intraoperative percutaneous double-balloon valvuloplasty versus surgical commissurotomy for mitral valve stenosis

Abstract

I n patients with pure mitral stenosis, a significant inThe study population consisted of 10 patients (4 men crease in valvular area can be obtained by a percutaneand 6 women, mean age 46 f 8 years) with severe pure ous approach with balloon valvuloplasty, by surgical mitral stenosis (mitral valve regurgitation <grade 1 closed commissurotomy, and by a selective eye-guided of Sellers classification), no or mild leafret calcium reparative procedure during cardiopulmonary bypass. and Block echocardiographic score 18. Patients with The surgical closed mitral commissurotomy for treatmarked dysfunction of the subvalvular apparatus were ment of mitral stenosis was first described by Cutler in excludedfrom the study. Allpatients underwent double1924 and is still the most common surgical procedure in balloon dilatation of the mitral valve and subsequently most countries. The open surgical commissurotomy, surgical open commissurotomy during cardiopulmonary more recently introduced, together with the mitral valve bypass. replacement represent a more appropriate choice in paDuring cardiopulmonary bypass the left atrium was tients with leaflet calcification, subvalvular disease or left opened, the mitral valve inspected and its area measured atria1 thrombus. Percutaneous balloon mitral valvuloby a Hegar calibrator. Two balloons (20 and 15 mm in plasty was first described by Inoue et all in 1984 as a diameter) were advanced across the mitral valve and nonsurgical therapeutic approach to surgical commissursimultaneously inflated with saline solution at 5 atm, otomy in patients with pure mitral stenosis. Al Zaibag et After the procedure the surgeon performed a complete al* subsequently developed the double-balloon technique reparative procedure opening the commissures not yet to obviate the noncommercial availability of the Inoue split and mobilizing tendinous cords and papillary muscatheter. Under similar anatomic conditions, open-chest cles. Measurements of valve area were obtained after commissurotomy should be more effective in terms of balloon valvuloplasty and after surgical commissurfinal valvular area than techniques such as closed cornotomy. missurotomy or percutaneous balloon valvuloplasty that A 2-tailed Student’s t test was used to test the dtfferinduce a rude mechanical stress to the mitral commisences between interventions. Ap value <0.05 was considsures and leaflets. It has been recently suggested, howered significant. Results are expressed as mean f I ever, that balloon valvuloplasty provides hemodynamic standard deviation. results comparable to those obtained by either surgical Double-balloon valvuloplasty caused splitting of open or closed commissurotomy.3 The present study comboth commissures in Spatients, whereas only the anteropares intraoperative effects on final mitral valve area, as lateral commissures were opened in the remaining 5 paassessed by a Hegar calibrator, of percutaneous doubletients. The valve area increasedfrom I Sl f 0.24 to 3.28 balloon mitral valvuloplasty and open-chest commissurf 0.48 cm2 Cp <O.OOl) after double-balloon valvulootomy. plasty and to 5.2 f 0.56 cm2 after the surgicalprocedure From the Department of Cardiology and Cardiovascular Surgery, Uni@ <O.OOl compared with valvuloplasty) (Figure 1). No versity “La Sapienza” Rome, Italy. Manuscript received December 12, damage of the valvular apparatus was evident after dou1991; revised manuscript received April 2,1992, and accepted April 4. ble-balloon dilatation in any patient.