PERCUTANEOUS TRANSMITRAL COMMISSUROTOMY (PTMC)

Abstract

Background: Mitral stenosis is one of the grave consequences of rheumatic heart disease.Balloon valvuloplasty for stenosed mitral and pulmonary valves has been practiced with good results in theworld. Since Inoue et al. introduced balloon valvuloplasty in 1982, percutaneous transmitral commissurotomy(PTMC) has become the treatment of choice for mitral stenosis replacing surgical commissurotomy andmitral valve replacement in many cases. Objective: The aim of this study was to audit the proceduralsuccess, in hospital outcome in patients undergoing percutaneous trans-mitral balloon commissurotomy(PTMC) in our set up. Study Design: Observational cross sectional study. Place and Duration: The studywas conducted at Faisalabad Institute of Cardiology Faisalabad from March 2011 to December 2013.Materials and Methods: Total one hundred and twenty four patients underwent percutaneous transmitralcommissurotomy from March 2011 to December 2013. Any patient of age ≥ 10 years with mitral stenosiswho fulfills the inclusion and exclusion criteria for PTMC was enrolled in this study. A full history particularly,age, sex, occupation, address, symptoms regarding their referral for medical checkup was noted. Detailedclinical examination especially relevant cardiovascular examination of all the patients was done. ECG ofevery patient was done. Baseline routine investigations including blood complete with ESR, electrolytes,CRP, LFT, RFT was done in each case. A baseline echocardiography was performed in all patients. Mitralvalve area was calculated by planimetry and by pressure half time method. Severity of mitral stenosis wasgraded as: very sever stenosis (valve area <1cm2), severe (valve area 1- 1.5 cm 2) moderate (valve area1.5- 2 cm2) and mild (valve area > 2.0 cm2). To exclude any clot in LA and LA appendage Transesophagealechocardiography (TEE) was performed. In Cath Lab pre and post PTMC invasive hemodynamics includingLA, RA, RV, left ventricular end-diastolic pressure (LVEDP), and transmitral pressure gradient (PG) wascalculated. Those patients who have echo contrast on echocardiography were given 5000 IU heparinIV after septal puncture. Antibiotic prophylaxis was initiated in all patients thereafter. The procedure wasperformed under local anesthesia, if needed moderate sedation was given with midazolam. The procedurewas ended when either at least one commissure was splitted, adequate increase in mitral valve area orincrease in degree of MR or decrease in mean LA pressure to ½ of pre PTMC value or decrease in mitralvalve gradient was observed. After 24-48 hours patient was discharged and before discharge transthorasicecho was done to measure all the parameters as pre PTMC along with any echo finding of pericardialeffusion. Results: Total 124 patients were studied, 92(74.2%) were female and 32(25.8%) were maleshowing a female predominance. The mean age was 27.29±9.3. Most of the patients 58(46.8%) were inage group 21-30 years. 87(70.16%) patients were in atrial fibrillation and 37(29.83%) had sinus rhythm. Theprocedure was successful in 118(95.16%) patients. 2(1.6%) patients need urgent MVR due to severe MRand 1 (0.8%) died during procedure. Most of the patients 85(68.55%) were in NYHA class III. After PTMC,ASD was present in 13(10.5%) patients. After PTMC moderate MR was seen in 2(1.6%) and severe MR wasobserved in 4(2.173%) patients. Most of the patients 115(92.7%) before PTMC were in severe pulmonaryhypertension and after PTMC most of the patients 91(73.4%) were in mild pulmonary hypertension. PrePTMC mean MVA (cm2) was 0.684± 0.1226 and post PTMC it was 1.533± 0.281 cm2. Mean MVPG prePTMC was 26.178±5.94 mmHg and post PTMC it was 7.62±5.007 mmHg with significant p value 0.0001.Mean LA pressure before procedure was 29.68±8.137 mmHg and post PTMC it was 12.28±6.99 and pvalue was 0.0001. 10 patients had special problems, 3 had previous H/O PTMC, 3 were pregnant lady, onehas kyphoscoliosis, one had large IAS aneurysm, one had H/O CVA and one patient was suffering fromrenal cell carcinoma. Conclusions: The outcome of this study suggests that PTMC is a safe procedure inexperienced hand with good success rate and optimal results even in patients with special problems likepregnancy, previous CVA and redo cases.