Balloon Mitral Valvotomy Research Articles

Immediate and late outcome of percutaneous balloon mitral valvotomy in patients with significantly calcified valves

We assessed immediate and late outcome in 55 patients with significantly calcified valves (group 1) after balloon mitral valvotomy and compared the results with those from 60 patients with noncalcified or minimally calcified valves (group 2). After valvotomy, mitral valve area increased from 1.03 ± 0.30 cm 2 to 1.64 ± 0.35 cm 2 ( p = 0.0001) by echo planimetry in group 1 but was significantly smaller than the mitral valve area in grou 2 after valvotomy (1.94 ± 0.38 cm 2; p = 0.0001). At a mean follow-up period of 30 months (range 2 to 81 months), 51% of patients in group 1 and 83% in group 2 were symptom tree ( p = 0.0002). In group 2, 15 (27%) patients and in group 2, 4 (7%) patients had cardiac events ( p = 0.003). The risk ratio for cardiac events was 4.3 times greater in group 1 than in group 2. In group 1, the risk ratio for cardiac events was 3.2 times higher in patients age ≥65 years and in patients with atrial fibrillation. The 6-year cumulative cardiac event-free survival rate was 64% in group 1 and 90% in group 2 ( p = 0.005). In 75 (65%) patients who had follow-up echocardiographic study (35 in group 1 and 40 in group 2), mitral valve area decreased to 1.48 ± 0.42 cm 2 at follow-up in group 1 ( p < 0.01) and to 1.77 ± 0.50 cm 2 in group 2 ( p = 0.03). Restenosis occurred in 16 (46%) of 35 patients in group 1 and 10 (25%) of 40 in group 2 ( p = 0.06). We conclude that significant valve calcification affects the immediate results of balloon mitral valvotomy and greatly increases the risk of later cardiac events. However, more than half of such patients may still derive long-term benefits from balloon mitral valvotomy, especially if they are young and have normal sinus rhythm.

Percutaneous mitral balloon valvotomy for recurrent mitral stenosis after surgical commissurotomy

Immediate outcome and 4-year follow-up results of percutaneous mitral balloon valvotomy (PMV) in patients with previous surgical mitral commissurotomy are studied. Repeat surgical mitral commissurotomy in patients with previous surgical commissurotomy is associated with higher mortality and morbidity. PMV has been proven to be safe and could be an ideal alternative in this patient group. The results of 68 patients with previous surgical commissurotomy were compared with those of 261 patients without prior surgical intervention. A good outcome, defined as the final mitral valve area >1.5 cm 2, was obtained in 51% of the patients with prior surgical commissurotomy compared with 71% in the control group (p = 0.002). During the 4-year follow-up period, there were more patients who required mitral valve replacement (19% vs 7%; p = 0.004) and who were in New York Heart Association functional class III and IV (85% vs 71%; p = 0.02) among those with prior surgical commissurotomy. However, when these patients were divided according to echocardiographic score, those with a score ≤8 had immediate outcome and long-term results similar to those without prior commissurotomy. PMV can be performed safely in patients with prior surgical commissurotomy. Although results of long-term follow-up in these patients is not as good as those in patients without prior surgical commissurotomy, those with a low echocardiographic score had similar excellent long-term results.

717-5 Comparison of Six Year Follow-up Results of Balloon Mitral Valvotomy in Patients with and without Mitral Regurgitation

Previous studies have demonstrated that mitral regurgitation (MR) greatly influenced long-term outcome after surgical mitral commissurotomy in pts with mitral stenosis. However, this issue has not been addressed after balloon mitral valvotomy (BMV). We therefore examined 6 year follow-up (FU) data in 69 pts who presented MR assessed by angiography before BMV (group 1), and compared the results with 75 pts who had no MR (group 2). Mean FU period was 27 ± 20 mo in group 1 and 33 ± 23 mo in group 2 (p = NS). Comparison of pts baseline characteristics, mitral valve area (MVA) before and after BMV and FU results between the groups were: Clinical Profile Group 1 Group 2 p-value Age (yr) 57 ± 13 45 ± 16 0.0001 Sex: M/F 80%/20% 17%/83% NS NYHA-FC: III-IV 90% 81% NS Echo score &gt;8 22% 12% NS Fluoroscopic Ca 2+ 87% 60% 0.001 A.F 56% 19% 0.0001 Pre 2D MVA (cm 2 ) 1.06 ± 0.30 100 ± 027 NS Post 2D MVA (cm 2 ) 1.71 ± 0.35 1.88±0.41 0.01 FU NYHA class I 51% 88% 0.0001 Cardiac events (CE) 28% 9% &lt; 0.01 CE = stroke, repeat BMV, mitral valve replacement (MVR), and death Comparison of 6 year CE-free and MVR-free actuarial survival rates were: Gr 1/Gr 2 1-yr 2-yr 3-yr 4-yr 5-yr 6-yr p-value CE-free (%) 87/94 79/92 73/90 65/90 59/90 49/79 0.002 MVR-free (%) 93/96 89/96 82/96 78/96 78/96 65/84 0.01 Hazard risk ratio by Cox regression analysis was 3.7 (95% CI: 1.5-8.9) times greater for CE (p &lt; 0.01), and 4.0 (1.2–12.7) times greater for MVR (p &lt; 0.05) at FU in group 1 than in group 2. (1) MR before BMV increases risk for late CE, particularly requiring MVR in the early FU. (2) Pts with MR appears to be older with calcified valves and AF, and to obtain smaller MVA post BMV, all of which may exacerbate the poor later outcome. (3) Half of such pts may still derive long-term benefits from BMV.

910-22 Mitral Regurgitation (not Restenosis) is the Most Frequent Indication for Valve Replacement After Balloon Mitral Valvotomy

The indications for mitral valve replacement (MVR) after balloon mitral valvotomy (BMV) remain poorly characterized. Restenosis has been the focus of most concerns regarding the long-term need for re-BMV or MVR. We reviewed the indications for MVR after BMV in 770 patients during 3 years. Indication for MVR: &lt; 30 days (n = 34) &gt; 30 days (n = 47) Restenosis 0 15% CHF 0 30% Failed BMW 15% 9% MR 85% 46% MVR was necessary in 4.5% within 30 days of BMV The indication for MVR was mitral regurgitation (MR) in 3.8% and failed BMV in 0.7%. Late MVR (more than 30 days post BMV) was done in an additional 6.1%. MVR was most frequently necessary for increasing MR or symptoms due to mixed or multiple valve lesions (p &lt; 0.001). Restenosis (loss of half the initial gain in mitral area) accounted for only 15% of the indications for MVR. Restenosis is an infrequent indication for MVR after BMV. Other factors including initially insufficient enlargement of the mitral orifice, persistent symptoms, and progression of post-BMV MR are the major indications for MVR after balloon mitral valvotomy.

717-6 Indications, Complications and Mid-term Outcome of Percutaneous Balloon Mitral Valvotomy During Pregnancy

We performed double balloon mitral valvotomy (BMV) in 36 consecutive pregnant women (mean age 26 years). Pregnancy mean age was 26 weeks (range 14–38 weeks). Thirty patients (pts) had pliable valves, 4 pts semi pliable valves and 2 pts calcific valves at fluoroscopy. Four pts had moderately severe MS (MVA 1.4 to 1.7 cm 2 ). Moderate (2 +) mitral regurgitation (MR) was present in 2 pts. Thirty pts were in NYHA functional class III or IV and 6 pts were in class II. The patient's pelvic-abdominal area was shield. Double balloon technique was used in 35 pts and Inoue device in one pt. The total mean time of BMV was 76 ± 19 min and that of fluoroscopy was 18 ± 8 min. Left atrium pressure decreased from 28 ± 9 to 14 ± 5 mmHg, cardiac index increased from 3.2 ± 0.9 to 4.6 ± 1 l/mn/m 2 and MVA increased from 0.9 ± 0.2 to 2.5 ± 0.4 cm2 There were no mortality nor residual MS. Impressive symptomatic improvement was obtained in all pts but 1 who developed severe (4 +) MR and underwent mitral valve replacement 5 days later. Thirty three pts delivered at full-term, 31 pts delivered vaginally and 2 pts by cesarean section due to obstetrical problems; 30 babies were normal and 3 were hypotrophic. At mean 24 ± 11 months post partum follow-up, the 33 infants had shown normal growth and development. Pregnancy evolves normally in the 3 remaining pts. During pregnancy BMV is the treatment of choice of severe pliable MS. Indications may be broadened to pts with rigid and calcific valves and to pts who had moderately severe MS or associated moderate MR and refractory disability.

717-4 Balloon Valvotomy for Non-Ideal Commissurotomy Candidates

Results for balloon mitral valvotomy (BMV) are usually reported for large heterogenous groups. Different outcomes are expected for good commissurotomy candidates (Ideal) compared to patients with significant valve deformity who might otherwise be good MVR candidates (Non-Ideal). We defined Ideal as echo score ≤ 6 and Non-Ideal as score ≥ 9/age ≤ 72. Ideal Patients Non-Ideal Patients n 344 154 Age (years) 47 ± 12 54 ± 11 * NYHA 2.8 ± 0.7 2.9 ± 1.6 * Echo Score 4.8 ± 1.4 10.1 ± 1.3 * MVA pre→post 1 ± 0.3→1.8 ± 0.6 1 ± 0.3→1.7 ± 0.6 * MVR 30 days 5.2% 8.1% 3 Yr. Event Free 82% 62% * * = p &lt; 0.01 vs Ideal Immediate BMV results for ideal patients with pliable valves and non-ideal patients who would otherwise be MVR candidates are good. Three year event free survival is excellent in ideal patients. Non-ideal patients with significant valve deformity have freedom from death, MVR or repeat PTMC after three years in 62% of cases.

717-3 Do All Patients Undergoing Inoue Balloon Mitral Valvotomy Need Transesophageal Echo (TEE) to Exclude Left Atrial Thrombus?

To assess merits of TEE and transthoracic echo (TIE) to exclude left atrial body (B) or appendage (A) thrombus (T) before valvotomy, we performed both in 151 consecutive patients (mean age 30) with tight mitral stenosis and NYHA 11/111 disability (Group I). T detected on TEE T suspected on TEE Confirmed Surgery No T at Surgery PMV (i) 5(B + -A) 5 3 – 1 (ii) 5(A) 3 5 – – (iii) 3(A) – – 3 – (iV) 3(A) 2 – – 2 In (i), 1 pt refused surgery and 1 had PMV after 3 mths of warfarin. In (iv), 2 pts had PMV and 1 no procedure. Thus 10.5% pts showed thrombus on TEE; of these 81% were in AF and 3 were in SR. Following on this experience, the next 165 similar consecutive pts had TEE before PMV only if T was suspected on TTE. Group II: T suspected on TTE T detected on TTE Confirmed at Surgery (i) 7 (B + -A) 7 7 (ii) 20 (A) 11 – All 11 pts in (ii) with TEE thrombus had uneventful PMV Thus only 16% had TEE. Of 38 pts having PMV without TEE, minor embolic episodes occurred in 3. All 3 had no evidence of T on post event TEE. In young pts carefully performed TTE is a useful screening procedure before PMV. TEE is not mandatory and should be performed if T suspected on TTE to exclude left atrial body thrombus as Inoue PMV IS safe in presence of appendage thrombus.

Clinical Follow-up of Patients Undergoing Percutaneous Mitral Balloon Valvotomy

This study is the clinical follow-up (20 +/- 12 months; range, 6 to 49 months) of 327 patients who had percutaneous mitral balloon valvotomy (PMV) at the Massachusetts General Hospital. There were seven in-hospital deaths. Patients were divided into two groups according to their echocardiographic score; 211 patients had echocardiographic scores < or = 8 and 116, echocardiographic scores > 8. Patients with echocardiographic scores > 8 were older (64 +/- 11 versus 48 +/- 14 years, P < .01), and more had atrial fibrillation (65% versus 40%, P < .01), calcium under fluoroscopy (81% versus 29%, P < .01), and previous surgical commissurotomy (30% versus 16%, P < .01) than patients with echocardiographic scores < or = 8. With PMV, mitral valve area increased from 1.0 +/- 0.3 to 2.2 +/- 0.8 cm2 in patients with echocardiographic scores < or = 8 and from 0.8 +/- 1 to 1.7 +/- 0.7 cm2 in those with echocardiographic scores > 8. Rates of survival (98 +/- 2% versus 72 +/- 11%), survival with freedom from mitral valve replacement (91 +/- 4% versus 55 +/- 13%), and survival with freedom from combined events (79 +/- 10% versus 39 +/- 18%) at follow-up were greater in patients with echocardiographic scores < or = 8 (P < .00005). Cox regression analysis identified the echocardiographic score as the most important unfavorable intermediate long-term follow-up prediction factor after PMV. The excellent intermediate long-term clinical follow-up of patients with echocardiographic score < or = 8 and no calcified mitral valves suggests that PMV may be the treatment of choice in this group of patients.

MITRAL BALLOON VALVOTOMY HAS EXCELLENT LONG-TERM OUTCOMES.

Percutaneous mitral balloon valvotomy (PMV) has been proposed as an alternative to surgical commissurotomy for patients with rheumatic mitral stenosis. This report describes the clinical outcomes of 327 patients who underwent PMV at …

Effect of atrial septal occlusion on mitral area after Inoue balloon valvotomy

The purpose of this study was to examine the influence of the atrial communication created during transseptal passage of the Inoue balloon catheter on calculated mitral valve area after balloon valvotomy for severe mitral stenosis. Even in the absence of oxymetric evidence for a shunt, atrial septal puncture may result in left-to-right shunting of blood with reported spurious increases in postvalvotomy mitral valve area calculations ranging from 16-29% in prior studies. Occlusion of the septal puncture site after double balloon valvotomy has previously been shown to result in decreased postvalvotomy mitral valve area determinations. We evaluated 20 patients undergoing mitral dilation. Each patient had three postvalvotomy measurements made: (1) with the Inoue balloon catheter positioned across the septum, (2) during septal occlusion with a 7F balloon-tip catheter, and (3) without any catheters across the septum. With the Inoue catheter across the septum after successful valvotomy, the cardiac output was 4.6 +/- 1.5 L/min and the calculated mitral valve area was 1.7 +/- 0.5 cm2. No difference was found in either cardiac output or valve area when the septum was unobstructed by catheters. During septal occlusion, however, the postvalvotomy cardiac output decreased to 4.3 +/- 1.3 L/min (P < 0.001) and the calculated mitral area decreased by 12% to 1.5 +/- 0.5 cm2 (P < 0.001). The calculated mitral valve areas determined with the Inoue catheter in place after valvotomy were in agreement with echo derived data. Although statistically significant differences in post-Inoue valvotomy cardiac output and calculated mitral valve area were found during septal occlusion, these differences were small.(ABSTRACT TRUNCATED AT 250 WORDS)

Thermodilution left-sided cardiac output for valve area determination after balloon mitral valvotomy

This study was conducted to establish the validity of left-sided cardiac output measurement with a Swan-Ganz catheter and assess its accuracy in estimating mitral valve area (MVA) by the Gorlin formula. The use of right-sided cardiac output after balloon mitral valvotomy (BMV) can give inaccurate measurements for Gorlin-derived MVA because of the atrial septal defect (ASD) created during the procedure. The left-sided cardiac output was measured with a Swan-Ganz catheter (proximal port in the left atrium and then in the left ventricle, and distal port in the ascending aorta) in 10 consecutive patients before and after BMV. Gorlin-derived MVA cardiac output by this method was compared with (1) Gorlin-derived MVA by means of right-sided cardiac output with and without balloon occlusion of the ASD and (2) MVA measured by echocardiography. Before BMV, a close agreement with a good correlation between left-sided and right-sided cardiac output was found ( r = 0.83, p = 0.006). Furthermore, Gorlin-derived MVA by cardiac output with either method was comparable with valve area by echo. After BMV, left-sided cardiac output correlated well ( r = 0.92, p = 0.0002) and was comparable with right-sided cardiac output with occlusion of the ASD (mean difference 0.17 ± 0.49 L/min, p = 0.3) but was significantly lower than the value obtained with open ASD (mean difference 0.93 ± 0.77 L/min, p = 0.004). Comparison of the correspondent MVAs yielded similar results. Gorlin-derived MVA with left-sided cardiac output and MVA by echo were also similar. Thermodilution left-sided cardiac output with a Swan-Ganz catheter is feasible and reliable, and improves the accuracy of Gorlin-derived MVA after BMV. This method may eliminate the need to close ASD for right-sided cardiac output measurement and may obviate the need for a second venous approach to BMV.

Significant tricuspid regurgitation does not resolve after percutaneous balloon mitral valvotomy

A total of 318 consecutive patients with mitral stenosis underwent percutaneous mitral valvotomy at our institution from 1987 to 1993. Of those, 98 patients had color Doppler echocardiographic studies performed before, 24 hours after, and late after the intervention. On the basis of color Doppler echocardiographic grading of tricuspid regurgitation, 32 patients (32%; mean age 57 ± 15 years) had significant (moderate or severe) tricuspid regurgitation before the intervention and were the subject of this study. The follow-up study was performed 18.4 ± 13 months after the procedure. Successful percutaneous mitral valvotomy (≥1.5 cm2valve area or ≥50% increase after valvotomy) with no restenosis at follow-up was achieved in 20 patients. Tricuspid regurgitation decreased by one grade (from severe to moderate) in only four subjects in this group and in none of the 12 patients who did not meet the criteria for successful percutaneous mitral valvotomy or who had restenosis. Thus tricuspid regurgitation did not improve in 88% of all patients studied. On average, no significant change was observed in the ratio of maximal tricuspid regurgitant jet area to right atrial area 24 hours after percutaneous mitral valvotomy and at late follow-up (37% vs 33% vs 34%, respectively) or in any of the right heart dimensions, even in patients who underwent successful percutaneous mitral valvotomy. Right ventricular systolic pressure also did not change significantly on average in those patients (46 ± 15 versus 42 ± 14 versus 48 ± 18 mm Hg, respectively). However, right ventricular dimensions did not decrease and tricuspid regurgitation did not resolve even in a subgroup of patients in whom right ventricular systolic pressure fell by more than 10 mm Hg (up to 41 mm Hg). (J T HORAC CARDIOVASC SURG 1994;108:727-35)

Mitral balloon valvotomy in children with Inoue balloon technique: Immediate and intermediate-term result

Percutaneous mitral balloon valvotomy (PMV) using the Inoue balloon technique was attempted in 170 patients. Of these, 30 patients were children aged 10 to 18 years (mean 15.9 ± 2.7 years). There were 16 female and 14 male patients. All were in sinus rhythmn. The procedure was successful in 28 patients (93%). PMV was performed using 20 to 28 mm (mean 25 mm) diameter balloon catheters with an echo-Doppler guided stepwise mitral dilation technique. After PMV, the mean left atrial pressure decreased from 25 ± 5 to 14 ± 4 mm Hg ( p < 0.001). The mean mitral valve gradient (MVG) decreased from 16 ± 4 to 6 ± 3 mm Hg ( p < 0.001). The mitral valve area (MVA) by catheter increased from 0.7 ± 0.2 to 1.7 ± 0.5 cm 2 ( p < 0.001), and MVA as determined by echocardiography (2DE) increased from 0.8 ± 0.1 to 1.9 ± 0.3 cm 2 ( p < 001). There were no deaths or thromboembolic complications; cardiac tamponade developed in one patient, mild mitral regurgitation (MR) developed in three patients (10%) and increased by one grade from (1+ to 2+) in another two patients (8%). A small atrial septal defect (ASD) assessed by color flow mapping developed in seven patients (25%); 90% were closed at 3 months. The Doppler and 2DE MVAs were maintained at 1.8 ± 0.4 cm 2 at 17 months' mean follow-up; one patient developed restenosis. We conclude the PMV using the Inoue balloon catheter is safe and effective in the treatment of severe mitral stenosis in children, with a low complication rate.

Percutaneous mitral balloon valvotomy in patients with calcific mitral stenosis: Immediate and long-term outcome

Objectives. This study analyzed the immediate and long-term outcome of percutaneous balloon mitral valvotomy in patients with and without fluoroscopically visible mitral valve calcification.Background. Mitral valve calcification has been shown to be an important factor in determining immediate and long-term outcome of patients undergoing surgical mitral commissurotomy. Patient selection has an important impact on the outcome of percutaneous balloon mitral valvotomy.Methods. The immediate and long-term results of percutaneous balloon mitral valvotomy were compared in 155 patients with and 173 patients without mitral valve calcification. The patients with calcified valves were assigned to four groups according to severity of calcification.Results. Patients with calcified mitral stenosis more frequently were in New York Heart Association functional class III or IV and more frequently had atrial fibrillation, previous surgical commissurotomy, echocardiographic score >8, higher pulmonary artery and left atrial pressures, higher pulmonary vascular resistance and mean mitral valve gradient and lower cardiac output and smaller mitral valve area. Mitral valve area after valvotomy was significantly smaller in patients with calcified valves (1.8 ± 0.06 vs. 2.1 ± 0.06 cm2) and was ≥1.5 cm2in 65% of patients with and 83% of patients without calcified valves (p = 0.004). A successful outcome, defined as mitral valve area >1.5 cm2without significant mitral regurgitation and left to right shunting, was achieved in 52% of patients with and 69% of patients without uncalcified valves (p = 0.001). The success rate was 59%, 48%, 35% and 33% insubgroups with 1+, 2+, 3+ and 4+ calcification, respectively. The rates of significant left to right shunting and mitral regurgitation after valvuloplasty were similar in the two groups. Estimated survival rate (80% vs. 99%, respectively, p = 0.0001), survival rate without mitral valve replacement (67% vs. 93%, respectively, p < 0.00005) and event-free survival rate (63% vs. 88%, respectively, p < 0.00005) at 2 yean were significantly better in the patients with uncalcified valves. Survival rate curves became progressively worse as the severity of calcification increased.Conclusions. These findings indicate that immediate and long-term results of mitral valvuloplasty are not as successful in patients with fluoroscopically visible mitral valve calcification as in those without calcification.

Transesophageal echocardiographic evaluation of mitral valve morphology to predict outcome after balloon mitral valvotomy

1. Hyperhomocysteinemia: an independent risk factor or vascular disease. New Engl 11. Wilcken DEL, Wilcken B. Pathogens324:1149-1155. role for methionine metabolism. J Clin Invest 1976;57:1079-1082. 14. Israelsson B, Brattsuom LE, Hultberg BJ. Homocysteine and myocardial in12. Beers GHJ, Schoonderwaldt HC, Schulte BPM, Trijbels JMF, Smals RGH, farction. Atherosclerosis 1988;71:227-233. Kloppentq PWC. Heterozygosity for homocystinuria: a risk factor for occlusive 15. Genest JJ, McNamara JR, Salem DN, Wilson PWF, Schaefer El, Malinow MR. cerebrovascular disease? C/in Gene? 1983;24:30&301. Plasma homocyst(e)ine levels in men with premature coronary artery disease. J Am 13. Clarke R, Daly L, Robinson K, Naughten E, Cahalane S, Fowler B, Graham Co//Car&/ 1990;16:111&1119.

Propranolol for pulmonary oedema in mitral stenosis

We report the case of a young adult with mitral stenosis and pulmonary oedema who did not respond to conventional antifailure therapy, but improved with intravenous propranolol and later underwent successful balloon mitral valvotomy. Intravenous beta blockade, though contraindicated in most cases of pulmonary oedema, may benefit patients with mitral stenosis and tachycardia.

Percutaneous mitral balloon valvotomy for patients with mitral stenosis

This study reports the immediate outcome, in-hospital complications, and long-term clinical follow-up of patients undergoing percutaneous mitral balloon valvotomy. In most series, this procedure is reported to increase mitral valve area from less than 1.0 cm2 to at least 2.0 cm2. The most important predictor of the immediate outcome of percutaneous mitral valvotomy is the echocardiographic score. The best results with percutaneous mitral valvotomy occur in those patients with echocardiographic scores of 8 or less. Mortality and morbidity with percutaneous mitral valvotomy are low and similar to surgical commissurotomy. There is less than 1% mortality, a 0% to 3.1% incidence of thromboembolic episodes and stroke, a 1% to 5.2% incidence of severe mitral regurgitation, a 0.2% to 4.1% incidence of pericardial tamponade, and a 3% to 16% incidence of left-to-right shunt. Survival (83 +/- 6% vs 48 +/- 8%), survival with freedom from mitral valve surgery (58 +/- 5% vs 25 +/- 5%), and event-free survival (51 +/- 6% vs 22 +/- 5%) at 80-month follow-up was greater in patients with echocardiographic scores of 8 or less compared with those with scores greater than 8 (P < 0.0001). Thus, the excellent immediate and long term results of percutaneous mitral valvotomy in patients with echocardiographic scores of 8 or less suggest that this procedure may be the treatment of choice in this group of patients.

Percutaneous Mitral Balloon Valvotomy-Reply

In Reply. —Dr Leachman draws attention to the difference in relative costs of closed surgical commissurotomy vs balloon commissurotomy in different countries. We note this point in the text of our article (page 1734, Hospitalization and Costs).1Turi et al2have studied this issue specifically in a population treated in India, where the cost of disposable, nonreusable balloon catheters is relatively high. We do not feel that a return to the practices of the 1950s would advance the treatment of patients with mitral stenosis substantially. Further efforts to develop balloon catheters that can be sold at a lower cost or reused easily might provide a more attractive alternative. We hope also that cost-effectiveness studies will take into account the difference between a thoracotomy and a percutaneous procedure from the patient's perspective. Balloon mitral valvotomy may be performed as easily as closed surgical commissurotomy with adjunctive use of a

Percutaneous Mitral Balloon Valvotomy

To the Editor. —Drs Carrol 1 and Feldman 1 state that mitral balloon valvotomy has proven to be safe and cost-effective. I have some question with regard to the cost-effectiveness, since it requires a catheterization laboratory, the installation of which costs an average of $1 million or more. The balloon catheter itself costs several thousand dollars. If, indeed, we are looking for similar palliative therapy, then I believe it would be considerably more cost-effective to return to the practice of the 1950s and 1960s, during which the diagnosis of mitral stenosis was made with a considerable degree of confidence only by auscultation, and many of these patients were successfully treated by closed commissurotomy technique, with similar outcome to that being described for balloon valvuloplasty. In reality, the technique of balloon valvuloplasty is not cost-effective in countries with a low medical budget.

Efficacy of mitral balloon valvotomy in reducing the severity of associated tricuspid valve regurgitation

In patients with rheumatic mitral stenosis, concomitant tricuspid regurgitation (TR) has been reported in 22 to 35%. 1,2 The mechanism of TR may be due to rheumatic disease of the tricuspid leaflets themselves, or functional secondary to pulmonary hypertension with subsequent dilatation of the right ventricle and tricuspid annulus. 2–6 The management of TR in patients undergoing mitral valve replacement has been debated by several investigators and remains controversial. 7–14 Although successful mitral valve surgery, 2,15 and more recently, mitral balloon valvotomy (MBV) 16–17 have both been shown to be associated with reductions in pulmonary arterial pressure and resistance, whether this is necessarily accompanied by an amelioration of TR is unknown. Data after mitral valve surgery are numerous but conflicting, 7–14 and no studies are available on the effects of MBV, if any, on the severity of TR.