Commissural Splitting Research Articles

Three-dimensional Echocardiography during Percutaneous Mitral Balloon Valvuloplasty

Percutaneous mitral balloon valvuloplasty (PMBV) has been frequently used as an alternative to open or closed surgical mitral commissurotomy for the treatment of selected patients with symptomatic rheumatic mitral stenosis. PMBV has been proven a safe and effective method, often performed under fluoroscopic guidance. With the advent of three-dimensional echocardiography (3DE), interventional cardiologists have been able to successfully perform complex procedures such as paravalvular leak closure, transcatheter edge-to-edge repair of the mitral valve (MV) using MitraClip, etc. With the expertise derived from these procedures, 3DE has received considerable interests in many other procedures, including PMBV. Pre-, intra-, and postprocedural assessments of the mitral valve (MV) area; commissural splitting; the presence, degree, and location of mitral regurgitation; and other procedure-related complications can be more accurately and readily made using 3DE. In addition, real-time 3D transesophageal echocardiography has been proven to be more accurate than two-dimensional (2D) techniques in identifying specific MV abnormalities associated with complex diseases. Moreover, real-time 3DE offers the advantage of shorter fluoroscopy and radiation times throughout PMBV. This article reviews the use of 3DE during PMBV in light of the most recent literature and based on expertise and discusses the pros and cons of 3DE, with emphasis on its superiority to conventional 2D echocardiography.

Mitral Regurgitation After Percutaneous Mitral Valvuloplasty: Insights Into Mechanisms and Impact on Clinical Outcomes

ObjectivesThe aim of this study was to assess the incidence, mechanisms, and outcomes of mitral regurgitation (MR) after percutaneous mitral valvuloplasty (PMV). BackgroundSignificant MR continues to be a major complication of PMV, with a wide range in clinical presentation and prognosis. MethodsConsecutive patients with mitral stenosis undergoing PMV were prospectively enrolled. MR severity was evaluated by using quantitative echocardiographic criteria, and its mechanism was characterized by 3-dimensional transesophageal echocardiography, divided broadly into 4 categories based on the features contributing to the valve damage. B-type natriuretic peptide levels were obtained before and 24 h after the procedure. Endpoints estimated cardiovascular death or mitral valve (MV) replacement due to predominant MR. ResultsA total of 344 patients, ages 45.1 ± 12.1 years, of whom 293 (85%) were women, were enrolled. Significant MR after PMV was found in 64 patients (18.6%). The most frequent mechanism of MR was commissural, which occurred in 22 (34.4%) patients, followed by commissural with posterior leaflet in 16 (25.0%), leaflets at central scallop or subvalvular damage in 15 (23.4%), and central MR in 11 (17.2%). During the mean follow-up period of 3 years (range 1 day to 10.6 years), 60 patients reached the endpoint. The event-free survival rates were similar among patients with mild or commissural MR, whereas patients with damaged central leaflet scallop or subvalvular apparatus had the worst outcome, with an event-free survival rate at 1 year of only 7%. Long-term outcome was predicted by net atrioventricular compliance (Cn) at baseline and post-procedural variables, including valve area, mean gradient, and magnitude of decrease in B-type natriuretic peptide levels, adjusted for the mechanism of MR. ConclusionsSignificant MR following PMV is a frequent event, mainly related to commissural splitting, with favorable clinical outcome. Parameters that express the relief of valve obstruction and the mechanism by which MR develops were predictors of long-term outcomes.

Additive value of 3D-echo in prediction of immediate outcome after percutaneous balloon mitral valvuloplasty

BackgroundResults of percutaneous balloon mitral valvuloplasty (BMV) are basically dependent on suitable patient selection. Currently used two-dimensional (2D) echocardiography (2DE) scores have many limitations. Three-dimensional (3D) echocardiography (3DE)-based scores were developed for better patient selection and outcome prediction. We aimed to compare between 3D-Anwar and 2D-Wilkins scores in mitral assessment for BMV, and investigate the additive value of 3DE in prediction of immediate post-procedural outcome. Fifty patients with rheumatic mitral stenosis and candidates for BMV were included. Patients were subjected to 2D- and real-time 3D-transthoracic echocardiography (TTE) before and immediately after BMV for assessing MV area (MVA), 2D-Wilkins and 3D-Anwar score, commissural splitting, and mitral regurgitation (MR). Transesophageal echocardiography (TEE) was also undertaken immediately before and intra-procedural. Percutaneous BMV was performed by either multi-track or Inoue balloon technique.ResultsThe 2DE underestimated post-procedural MVA than 3DE (p = 0.008). Patients with post-procedural suboptimal MVA or significant MR had higher 3D-Anwar score compared to 2D-Wilkins score (p = 0.008 and p = 0.03 respectively). The 3D-Anwar score showed a negative correlation with post-procedural MVA (r = − 0.48, p = 0.001). Receiver operating characteristic (ROC) curve analysis for both scores revealed superior prediction of suboptimal results by 3D-Anwar score (p < 0.0001). The 3DE showed better post-procedural posterior-commissural splitting than 2DE (p = 0.004). Results of both multi-track and Inoue balloon were comparable except for favorable posterior-commissural splitting by multi-track balloon (p = 0.04).ConclusionThe 3DE gave valuable additive data before BMV that may predict immediate post-procedural outcome and suboptimal results.

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

Whether percutaneous mitral commissurotomy (PMC) should be attempted in patients with severe mitral stenosis and commissural calcifications remains debated, since commissural splitting is the mechanism by which mitral valve stenosis is relieved. To determine whether the presence of calcium in the mitral valve commissures influence the immediate result of PMC. PMC by the Inoue balloon was attempted in 247 patients (mean age: 35 years) with severe mitral valve stenosis. 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 ≥ grade3. 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) occured 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 contra-indication to PMC.

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

Background Whether percutaneous mitral commissurotomy (PMC) should be attempted in patients with severe mitral stenosis and commissural calcifications remains debated, since commissural splitting is the mechanism by which mitral valve stenosis is relieved. Purpose To determine whether the presence of calcium in the mitral valve commissures influence the immediate result of PMC. Methods PMC by the Inoue balloon was attempted in 247 patients (mean age: 35 years) with severe mitral valve stenosis. 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 ≥ grade3. Results After PMC, the mean MVA increased to 1.79 ± 0.34 cm2 (P Conclusion 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 contra-indication to PMC.

Immediate and ten years long term results of a new balloon mitral valvuloplasty technique

Background Percutaneous balloon mitral valvuloplasty (PBMV) is the standard non-surgical treatment of rheumatic mitral stenosis (MS). The success of PBMV depends on achieving higher mitral valve area (MVA) with commissural splitting. The direction of major force is an important determinant of PBMV outcome. Single balloon direct the major force toward the leaflet while double balloon technique direct the force toward the commissures. Objectives To test the hypothesis that stepwise dilation of mitral valve using single followed by double balloons (Bonhoeffer multi-track system) inflations would gradually apply bidirectional forces and hence yield better outcome. Methods Six hundred and twenty-four patients with symptomatic MS were prospectively randomized to either standard multi-track PBMV (group I: 381 pts had simultaneous inflation of two equal size balloons), or new modified technique (group II: 243 pts had stepwise dilation using single 20 mm balloon inflation followed by double balloon inflation, i.e., 20 + 16, 18, or 20 mm to body surface area). Results Both groups had comparable basic data: mean age (19.03 ± 6.44 vs. 18.62 ± 6.24 years), male/female ratio (70/311 vs. 32/211), echo score (6.18 ± 1.29 vs. 6.32 ± 1.38), MVA (0.82 ± 0.18 vs. 0.84 ± 0.12 cm 2 ), and trans-mitral gradient (26.94 ± 6.19 vs. 27.41 ± 7.13 mmHg). They had similar success rates (96.8% vs. 95.9%). Modified technique achieved significantly higher MVA (2.19 ± 0.34 vs. 1.87 ± 0.96 cm 2 , p = 0.0001) with more opened commissures (65% vs. 49.1%, p = 0.0001), and less mitral regurgitation (30/243 vs. 77/381, p = 0.011). In long term follow up, modified technique had significant lower restenosis rate (9.46% vs. 23.88%, p = 0.0001), redo surgery (2.88% vs. 7.34%, p = 0.029), and mitral valve area gain loss (0.09 ± 0.04 vs. 0.27 ± 0.06 cm 2 , p = 0.0001). Kaplan–Meier curve revealed no differences (hazard ratio = 1.04, 95% CI = 0.53 ± 2.01, p = 0.901) of total events (death, perforation, thrombo-embolism, atria-fibrillation, and large ASD). Conclusions This study demonstrates the benefits of applying bidirectional stepwise forces using modified multi-track technique which resulted into higher post dilation valve areas, less incidence of mitral regurgitation and lower long term restenosis rate.

AS-297: Balloon Aortic Valvuloplasty –A Case Series of 105 Patients

Balloon Aortic Valvuloplasty(BAV) has definitive role as safe palliative treatment in severe symptomatic aortic stenosis and as a bridge to definitive therapy. Renewed interest in this procedure is seen with significant advances in transcatheter aortic valve implantation.BAV relieve aortic stenosis by commissural splitting in congenital and rheumatic aortic stenosis, whereas in degenerative calcific aortic stenosis it do so by fracture of nodular calcium.This study analyse safety and effectiveness of BAV for severe aortic stenosis of various etiology and here we report single centre experience of 105 cases in 13 years.

Immediate and 18‐Month Outcome of Balloon Mitral Valvuloplasty: Comparison of Inoue and Multi‐Track System

Aims: To compare the immediate and 18‐month clinical and echocardiographic outcome of Inoue and multi‐track system for balloon mitral valvuloplasty (BMV). Methods: We included 78 consecutive patients with moderate to severe rheumatic mitral stenosis (MS) [mitral valve area (MVA) &lt; 1.5 cm2] and clinically indicated BMV. The first 42 consecutive patients were assigned to Inoue BMV (group I), and the following 36 consecutive patients were assigned to multi‐track system (group M). Clinical and echocardiographic assessment was performed before, immediately after, 3 months after, and 18 months after the procedure. Results: The successful immediate result [MVA &gt; 1.5 cm2 and mitral regurgitation (MR) &lt; II/IV] was achieved in 40 (95.23%) patients of group I and 34 (94.44%) patients of group M (P = 0.12). Immediately after BMV, MVA increased from 0.9 ± 0.4 to 1.7 ± 0.5 cm2 in group I and from 0.8 ± 0.2 to 1.9 ± 0.3 cm2 in group M (P &lt; 0.01). Bilateral commissural splitting was significantly higher in group M (P &lt; 0.01). This was associated with higher incidence of mild commissural mitral regurgitation. There were no significant differences of moderate to severe MR. Both procedure and fluoroscopy time were significantly shorter in group I (P &lt; 0.001). Eighteen‐month clinical and echocardiographic evaluation was available for 66 (84.64%) patients with sustained immediate clinical and echocardiographic improvements. Conclusions: Both Inoue and the multi‐track balloon systems achieved successful immediate and 18‐month results. The multi‐track double balloon system produced significantly larger MVA, with better bilateral commissurotomy, yet with longer procedure and fluoroscopy times. (J Interven Cardiol 2012;25:47–52)

Validation of a New Score for the Assessment of Mitral Stenosis Using Real-Time Three-Dimensional Echocardiography

The aim of this study was to validate a new real-time three-dimensional echocardiography (RT3DE) score for evaluating patients with mitral stenosis (MS). A two-staged study was conducted. In the first stage, the feasibility of a new RT3DE score was assessed in 17 patients with MS. The second stage was planned to validate the RT3DE score in 74 consecutive patients undergoing percutaneous mitral valvuloplasty. The new RT3DE score was constructed by dividing each mitral valve (MV) leaflet into 3 scallops and was composed of 31 points (indicating increasing abnormality), including 6 points for thickness, 6 for mobility, 10 for calcification, and 9 for subvalvular apparatus involvement. The total RT3DE score was calculated and defined as mild (<8), moderate (8-13), or severe (>or=14). MV morphology was assessed using Wilkins's score and compared with the new RT3DE score. In the first stage, the RT3DE score was feasible and easily applied to all patients, with good interobserver and intraobserver agreement. In the second stage, RT3DE improved MV morphologic assessment, particularly for the detection of calcification and commissural splitting. Both scores were correlated for assessment of thickness and calcification (r = 0.63, P < .0001, and r = 0.44, P < .0001, respectively). Predictors of optimal percutaneous mitral valvuloplasty success by Wilkins's score were leaflet calcification and subvalvular apparatus involvement, and those by RT3DE score were leaflet mobility and subvalvular apparatus involvement. The incidence and severity of mitral regurgitation were associated with high-calcification RT3DE score. The new RT3DE score is feasible and highly reproducible for the assessment of MV morphology in patients with MS. It can provide incremental prognostic information in addition to Wilkins's score.

Restenosis and adverse clinical events after successful percutaneous mitral valvuloplasty: immediate post-procedural mitral valve area as an important prognosticator

We sought to investigate the factors associated with restenosis and its potential association with late clinical deterioration after successful percutaneous mitral valvuloplasty (PMV). We analysed echocardiographic (median 74 months) and clinical (median 109 months) follow-up data of 329 patients who achieved procedural success, defined as mitral valve area (MVA) > or =1.5 cm(2) and mitral regurgitation (MR) < or =2/4, between 1995 and 2000. Clinical events included cardiovascular death, mitral valve surgery, and repeat PMV. The 1, 3, 5, 7, and 9 year rates of restenosis-free survival were 99 +/- 1%, 97 +/- 1%, 95 +/- 1%, 86 +/- 3%, and 72 +/- 4%, respectively. The 1, 3, 5, 7, and 9 year rates of event-free survival were 99.7 +/- 0.3%, 96.4 +/- 1.0%, 94.5 +/- 1.3%, 90.8 +/- 1.6%, and 90.0 +/- 1.7%, respectively. Immediate post-PMV MVA and commissural MR or splitting, indicators of procedural adequacy, were independent predictors of both restenosis and clinical events. The best immediate post-PMV MVA cut-off value for predicting both restenosis and clinical events within 5 years after successful PMV were 1.8 cm(2) [95% confidence interval (CI) = 1.7-1.9] and 1.9 cm(2) (95% CI = 1.7-2.0), respectively. Patients with immediate post-PMV MVA <1.8 cm(2) showed significantly lower event-free survival rate than those with post-PMV MVA > or =1.8 cm(2) (P < 0.001). Immediate post-PMV MVA> or =1.8 cm(2) was an important predictor of both restenosis- and clinical event-free survival and this value should be considered as a component of optimal result.

Three-dimensional evaluation of the mitral valve area and commissural opening before and after percutaneous mitral commissurotomy in patients with mitral stenosis

Management of patients with mitral stenosis (MS) relies on accurate evaluation of the mitral valve area (MVA). Planimetry (MVA(2D)) is considered as the reference method but must be performed at the tips of the leaflets with the correct plane orientation and therefore requires experienced operators. Real-time three-dimensional echocardiography (RT3DE) may overcome this limitation but its usefulness for experienced when compared with less experienced operators has not been evaluated. In addition, superiority of RT3DE for the evaluation of commissural splitting after percutaneous mitral commissurotomy (PMC) is unknown. 60 patients were prospectively evaluated by 2D and RT3DE before and after PMC by experienced operators. Before PMC, MVA(3D) was slightly higher than MVA(2D) (1.15 +/- 0.25 vs. 1.06 +/- 0.22 cm2, P = 0.0001) but correlation between methods was excellent (r = 0.73, P < 0.0001), mean difference was small (0.09 +/- 0.18 cm2) and clinically meaningless (three patients misclassified, two of whom had borderline MS severity). After PMC, MVA(3D) did not differ from and correlated well with MVA(2D) (1.87 +/- 0.37 vs. 1.85 +/- 0.32 cm2, P = 0.36; r = 0.76, P < 0.0001; mean difference 0.03 +/- 0.24 cm2). Twenty-five additional patients were also evaluated both by an experienced and a less experienced operators. Bland-Altman analysis showed the better agreement between MVA(3D) measured by the less experienced operator and MVA(2D) measured by the experienced operator than between MVA(2D) measured by the less experienced and the experienced operators (mean difference 0.03 +/- 0.34 vs. - 0.13 +/- 0.46 cm2, P = 0.03). When compared with RT3DE, 2DE underestimated the degree of commissural opening in 33% of patients and agreement between methods was weak (kappa = 0.41). RT3DE provides accurate MVA measurements similar to 2D planimetry performed by experienced operators. Thus, it does not provide a real advantage for experienced operators, whereas it seems particularly helpful for less experienced operators. In addition, RT3DE improves the description of valvular anatomy.

Mechanism of spontaneous diminution of mitral regurgitation following percutaneous mitral valvuloplasty with the Inoue balloon

To the Editor: stepwise technique of PBMV with the Inoue balloon [7,8] I agree with Krishnamoorthy et al. [1] that most patients with mitral regurgitation (MR) following percutaneous balloon mitral valvuloplasty (PBMV) with the Inoue balloon showed gradual improvement in their MR and symptoms. My colleagues in China and I [2] reported in 1995 the largest series of patients who underwent PBMV with the Inoue balloon technique. Among 4832 patients, 1.4% developed severe MR (z 3+/4+); emergency mitral valve replacement was performed in 6 patients and elective mitral valve replacement in 12; in most of the patients the preexisting MR did not show any significant change after PBMV [2]. The production of or increase in MR that followed PBMV improved in more than half of the patients at follow-up catheterization [3–5]. Four mechanisms have been postulated: (1) reversible mitral valve stretching by PBMV; (2) better leaflet coaptation following balloon dilation of the stenotic mitral valve; (3) fibrosis and healing of the end of the commissures which may diminish MR resulting from excessive commissural splitting; and (4) improvement in transient papillary muscle dysfunction caused by balloon trauma to the papillary muscles at the time of PBMV [6]. Therefore I always advise watchful waiting in managing mild to moderate MR that followed PBMV with the Inoue balloon. The MR murmur in many of these patients diminished in intensity, or even disappeared, over the follow-up period. Clinically they remained much improved. If the

Comparative Study Between Various Methods of Percutaneous Transvenous Mitral Commissurotomy Metallic Valvotome, Inoue Balloon, and Double-Balloon Techniques (VID) Study

The aim of this study was to compare the immediate results of percutaneous mitral commissurotomy using metallic valvotome, Inoue balloon, or double-balloon techniques. We conducted a randomized trial comparing the immediate results of the three procedures in 150 patients (50 patients in each group) who were rheumatic mitral stenosis candidates for valvuloplasty. The procedures used per group were metallic valvotome (group I), Inoue balloon (group II), and double balloon (group III). The three groups were similar in age, sex, MVA, transmitral PG, LV function, predicted PAP, and presence of mitral re gurgitation. Patients in group I had a higher MV score (>9) than group II and III. The MVA was increased by a similar degree in groups I and III (2.1 ± 0.5 cm2, 2.0 ± 1.2 cm2) but greater than group II (1.87 ± 0.4 cm2) (P = 0.01). Mean transmitral PG was lower in group III (4.3 ± 1.9 mmHg) than in groups I and II (6.3 ± 3.7 mmHg, 6.3 ± 5.3 mmHg), respectively (P = 0.01). Echocardiographic data showed a higher depth score of posterior commissural splitting in groups I and III (0.7 ± 0.3 cm, 0.8 ± 0.3 cm, respectively) than in group II (0.6 ± 0.3) (P = 0.006), while the depth score of anterior commissure splitting was comparable in all groups (0.6 ± 0.3, 0.6 ± 0.3, and 0.7 ± 0.3, respectively) (P = 0.4). Stepwise multivariate regression analysis revealed that the following variables significantly affect the success of valvuloplasty as evidenced by a MVA ≥ 1.5 cm2. (1) techniques, the larger MVA was achieved by valvotome and double balloon (P = 0.0001); (2) MVA before valvuloplasty, the larger the MVA before, the larger the MVA after (P = 0.0008); (3) valve thickness, the more the thickness, the smaller the achieved MVA (P = 0.01); und (4) valve mobility, the more limited mobility, the smaller the MVA (P = 0.007). Small and restrictive ASD was present in 14 (28%) patients in group I, 2 (4%) patients in group II, and 3 (6%) patients in group III. Changes in grade of mitral regurgitation was comparable in all groups as the grade increased by I grade (40% in group I, 36% in group II, and 36% in group III). In contrast to the Inoue balloon technique, the metallic valvotome, and double-balloon technique produced an excellent and comparable early improvement of MVA associated with minimal complications. However, the good results achieved with patients who had a higher MV score (≥9) by metallic valvotome and lower cost indicate that metallic valvotome should be the treatment of choice for tight mitral stenosis.

Long-term clinical and echocardiographic outcome of percutaneous mitral valvuloplasty: Randomized comparison of Inoue and double-balloon techniques

OBJECTIVESThe purpose of the present study was to compare the long-term clinical and echocardiographic results of the Inoue and the double-balloon techniques.BACKGROUNDThe large randomized trial comparing the extent of commissurotomy and the long-term results between the double-balloon and Inoue balloon techniques has not been reported.METHODSWe conducted a prospective, randomized trial comparing two procedures in 302 consecutive patients who underwent percutaneous mitral valvuloplasty (PMV) using Inoue (n = 152; group I) or double-balloon technique (n = 150, group D) between 1989 and 1995. The sample size was planned to provide the study with approximately 80% power for the detection of a 10% difference between the two groups.RESULTSThere were no significant differences in baseline characteristics between the two groups. Immediately after PMV, mitral valve area (MVA) increased from 0.9 ± 0.2 to 1.8 ± 0.3 cm2in group I and from 0.9 ± 0.2 to 1.9 ± 0.3 cm2in group D. No significant differences existed between the two groups in terms of development of commissural splitting, commissural mitral regurgitation (CMR), moderate to severe mitral regurgitation (MR) and MVA after PMV. The successful immediate results (MVA ≥1.5 cm2and MR ≤2) were achieved in 127 (84%) patients of group I and 122 (81%) patients of group D (p = NS). Annual clinical and echocardiographic evaluation was completed for 290 (96%) patients with mean follow-up of 51 ± 27 months. Adverse events occurred in 19 (13%) patients of group I (3 deaths, 7 mitral valve replacements, 5 repeat PMV, 2 NYHA class ≥3, 2 technical failures) and 16 (11%) patients of group D (2 deaths, 10 mitral valve replacements, 3 repeat PMV, 1 NYHA class ≥3). Estimated actuarial seven-year event-free survival was 75 ± 7% in group I and 82 ± 6% in group D (p = NS). Estimated actuarial seven-year restenosis-free survival was 67 ± 7% in group I and 76 ± 6% in group D (p = NS). On multivariate analysis, unsuccessful immediate result (p < 0.001) and absence of CMR (p < 0.01) were independently related with events. Absence of CMR and smaller mitral valve area after PMV were independently related with restenosis (p < 0.001).CONCLUSIONSThe Inoue and double-balloon techniques were equally effective in commissurotomy and produced similar, excellent long-term results. The achievement of complete commissurotomy with development of CMR or larger post-PMV mitral valve area is important to optimize the long-term results of PMV.

Utility of three-dimensional echocardiography during balloon mitral valvuloplasty

Objectives. We investigated the role of three-dimensional echocardiography in assessing mitral valve anatomy in greater detail in patients immediately before and after balloon mitral valvuloplasty (BMV).Background. Three-dimensional echocardiography is a recently developed, evolving imaging technique that allows visualization of intracardiac structures from any perspective.Methods. We studied 19 patients undergoing BMV using transesophageal echocardiography (TEE) (Chicago, Illinois) to image the mitral valve. The TEE was interfaced to a TomTec three-dimensional workstation that allows electrocardiographic and respiratory cycle gated image acquisition. The acquired images are digitized, and after postprocessing a three-dimensional image is reconstructed. The mitral valve was viewed “en-face” as if looking up from the left ventricle.Results. The mean mitral valve area (by pressure half-time from the Doppler of the two-dimensional echocardiogram) increased after BMV from 0.86 ± 0.06 cm2to 2.07 ± 0.10 cm2, p < 0.0001. This was similar to the mitral valve areas obtained by planimetry from the three-dimensional images. The three-dimensional reconstructions showed a complete commissural split in 10 patients and partial splitting in 9 patients. In three of the eight patients who had an increase in the amount of mitral regurgitation secondary to BMV, the three-dimensional reconstructions were able to detect tears within the valve leaflet. One leaflet tear actually extended up to the mitral valve annulus and was associated with the only case of severe mitral regurgitation.Conclusions. The three-dimensional echocardiographic reconstruction enabled visualization of the mitral valve so that commissural splitting and leaflet tears not seen on the two-dimensional echocardiogram became visible.

A Prospective Echocardiographic Study of the Effects of Balloon Mitral Commissurotomy on Pre-Existing Mitral Regurgitation in Patients with Mitral Stenosis

Mitral regurgitation which is more than mild in severity is usually regarded as a relative contraindication to balloon mitral commissurotomy (BMC) because it is commonly believed that it may be worsened by the procedure. The aim of this study was to investigate the effects of BMC on pre-existing mitral regurgitation. Transthoracic and biplane transoesophageal echocardiography (TTE, TEE) combined with colour flow mapping (CFM) were performed prospectively on 50 consecutive patients immediately before and within 24 h after Inoue BMC. Before BMC, mitral regurgitation (MR) was diagnosed by TEE and left ventriculography in 36 and 13 patients respectively. Angiographic MR was mild in all 13 cases. The precise origins of MR jets were carefully sought by scanning in multiple TTE and TEE views. The maximal area of colour flow MR jets detected by TEE was measured by planimetry. After BMC mean mitral valve area increased from 1.0 ± 0.3 to 1.7 ± 0.8 cm², p < 0.0001, mean left atrial pressure and volume decreased from 23.7 ± 5.6 mm Hg to 21.6 ± 7.5 ml, p = 0.039, and from 105 ± 56 to 90 ± 46 ml, p = 0.002, respectively. MR jets as assessed by TEE CFM disappeared in 12 patients, in all of whom MR had been undetected by angiography. MR jets remained within 20% of their original sizes in 16 (44%) patients and more than doubled in only 3 patients. However, the latter had only mild angiographic MR after BMC. BMC created new MR jets, distinct from pre-existing ones, in 27 (75%) patients. Their aetiologies were commissural splitting in 24, leaflet tears in 2 and chordal rupture in 1 case. New MR jets were co-existent with old jets in 17 (47%) cases and in 10 (28%) cases old jets were replaced by new jets. The severity of angiographic MR was unchanged in 21 (58%) of the 36 patients; new jets, all originating from one or both commissures, were found in 13 (65%) patients on TEE. Angiographic MR increased by 1 grade in 11 (33%) patients; new jets were detected in 9 patients, 8 from the commissures and 1 due to chordal rupture; in only 1 of the 11 patients did the increase in MR appear to be due to a worsening of a pre-existing jet. Angiographic MR increased by 2 grades in 3 (8%) patients; new jets appeared in all 3, arising from the commissures in 2 and from a leaflet tear in 1 case. One patient with a leaflet tear sustained an increase of 3 grades in angiographic MR. The final degree of angiographic MR was nil in 13, mild in 15, moderate in 6 and severe in 2 patients. Leaflet tears were responsible for both cases of severe MR. BMC does not appear to affect pre-existing mitral regurgitation adversely in almost all patients. It may abolish trivial jets but in most cases it creates new jets alongside the old ones. Leaflet tears are responsible for severe mitral regurgitation after BMC and this is independent of pre-existing regurgitant jets.

Long-term Clinical Outcome and Echocardiographic Restenosis after Successful Percutaneous Transmitral Commissurotomy

Background:The purpose of this study was to assess the clinical outcome and echocardiographic incidence of restenosis after successful percutaneous transmitral commissurotomy(PTMC) and to identify predictable causes of restenosis. Methods:Between 1989 and 1992, Inoue PTMC(n=73) and double balloon technique(n=85) were used in 158 consecutive patients(male 52, age;41±11 year) with mitral stenosis. Clinical and echocardiographic examinations were performed annually in 137 patients who exhibited good initial results with PTMC(mitral valve area 1.5cm and mitral regurgitation[MR] 2+). Restenosis was defined as a mitral valve area(MVA) <1.5cm or more than 50% loss of the initial gain in MVA. Commissural mitral regurgitation(CMR) was defined as MR originating from medical or lateral commissure on color flow imaging and regarded as an index of complete commissural splitting. Results:Immediately after PTMC, MVA increased from 0.9±0.2cm to 1.8±0.3cm and functional class improved up to NYHA class 1 or 2 in all patients. Annual echocardiographic followups were completed in 129(94%) patients and mean follow-up duration was 54±21 months. Adverse events occurred in 16(13%) patients(1 death, 3 mitral valve replacements, 3 re-PTMCs, 9 deteriorations of the NYHA class), and restenosis occurred in 41(32%) patients. Event-free and restenosis-free survival rates at 7 years were 776% and 586%, respectively. According to multivariate Cox analysis, restenosis(p=0.0017, relative risk[r.r]=2.8) was the only predictor of adverse events;smaller increases(1.0cm) of MVA(p=0.0001, r.r=4.8) and the absence of CMR(p=0.0000, r.r=4.8) were independent predictors of restenosis.

Echocardiographic Assessment of Commissural Calcium: A Simple Predictor of Outcome After Percutaneous Mitral Balloon Valvotomy

Objectives. This study was undertaken to determine whether the presence of calcium in the mitral valve commissures, as demonstrated echocardiographically, could predict outcome and to compare this with an established echocardiographic scoring system.Background. Percutaneous mitral balloon valvotomy is an effective form of treatment for mitral valve stenosis. It is important to identify patients who would benefit from this procedure. Commissural splitting is the dominant mechanism by which mitral valve stenosis is relieved by this technique, and thus commissural morphology may predict outcome.Methods. One hundred forty-nine consecutive patients who underwent percutaneous mitral balloon valvotomy at the Mayo Clinic were evaluated retrospectively. The morphology of the mitral valve apparatus on the baseline echocardiograms was scored in blinded manner using a semiquantitative grading system of leaflet thickening, mobility, calcification and subvalvular thickening (Abascal score). Additionally, each of the medial and lateral commissures was graded for the presence or absence of calcification. End points were death, New York Heart Association functional class, repeat percutaneous mitral balloon valvotomy and mitral valve replacement at follow-up.Results. The mean follow-up period was 1.8 years (maximum 7.9 years). Univariate predictors of death and all events combined included age, the use of a double-balloon technique, the presence of calcium in a commissure and the Abascal score, as continuous variables. Patients with an Abascal score ≤8 showed a trend toward improved survival at 36 months free of death, repeat percutaneous mitral balloon valvotomy or mitral valve replacement (78 ± 6% vs. 67 ± 8%, p = 0.07) and free of all events combined (75 ± 6% vs. 64 ± 8%, p = 0.07) versus those patients with a score >8. However, survival at 36 months free of death, repeat percutaneous mitral balloon valvotomy or mitral valve replacement (86 ± 4% vs. 40 ± 4%) and free of all events combined (82 ± 5% vs. 38 ± 10%) at follow-up was significantly different between patients without commissural calcium and those with commissural calcium (p < 0.001). In a Cox regression model with Abascal score and commissural calcium and their interaction, calcification emerged as the only significant variable (p < 0.01).Conclusions. The presence of commissural calcium is a strong predictor of outcome after percutaneous mitral balloon valvotomy. Patients with evidence of calcium in a commissure have a lower survival rate and a higher incidence of mitral valve replacement and all end points combined. Thus, the simple presence or absence of commissural calcification assessed by two-dimensional echocardiography can be used to predict outcome.(J Am Coll Cardiol 1997;29:175–80)>

Continuous Spinal Analgesia with Sufentanil for Labor and Delivery in a Parturient with Severe Pulmonary Stenosis

Continuous Spinal Analgesia with Sufentanil for Labor and Delivery in a Parturient with Severe Pulmonary Stenosis

Echocardiographic restenosis after successful balloon dilatation of the mitral valve with the Inoue balloon: experience of a United Kingdom centre.

(a) To assess the echocardiographic incidence of restenosis after successful balloon dilatation of the mitral valve at a mid-term follow up of one year among a population of predominantly United Kingdom patients. (b) To identify any factors, assessed before or during dilatation, which may predict the development of restenosis. Successful dilatation of the mitral valve was defined as an increase in mitral valve area of > 25% and a final valve area of at least 1.5 cm2. Echocardiographic restenosis was defined at follow up as a loss of 50% of initial gain and a valve area of less than 1.5 cm2. Mitral valve area was assessed by transthoracic echocardiography before, during, 48 hours after, and one year after successful balloon dilatation of the mitral valve. Echo score before dilatation (an assessment of valvar and subvalvar calcification, thickening, and mobility), age, rhythm, echocardiographic mitral valve area before and after dilatation, left atrial pressure before and after dilatation, and end diastolic mitral valve gradient before and after dilatation were compared in those patients with and without echocardiographic restenosis at one year. A regional cardiothoracic centre in the United Kingdom that performs 20-30 balloon dilatations of mitral valves each year. 39 patients, with symptomatic dominant mitral stenosis, who had undergone successful balloon dilatation of the mitral valve, and in whom echocardiographic assessment of mitral valve area was available at one year. 92% of patients were citizens of the United Kingdom. Balloon dilatation of the mitral valve by the Inoue technique. Mitral valve area and patient symptom class (New York Heart Association) one year after successful dilatation of the mitral valve. The incidence of echocardiographic restenosis was eight of 39 patients (21%). Of the eight patients with restenosis four underwent mitral valve replacement, two had repeat dilatation of the mitral valve, and two remained on medical treatment. With univariant analysis, factors associated with restenosis were increased age, higher echo score before dilatation, and a lower mitral valve area immediately after the operation. The only independent risk factor for restenosis, shown by multivariant analysis, was a high echo score before dilatation. There was no significant fall in mitral valve area at one year in those patients without restenosis. Most (28/31) of these patients had echocardiographic evidence of splitting of at least one commissure after dilatation compared with only two of eight patients who developed restenosis. Of 10 patients with an echo score before dilatation > or = 10 only two had an initially successful operation and no restenosis at one year. The echocardiographic incidence of restenosis after dilatation of the mitral valve by the Inoue technique in patients of the United Kingdom is 21%. The principal factor associated with restenosis is a high echo score before dilatation. Increases in mitral valve area are maintained in those patients without restenosis and it is likely that the mechanism of initial increase in valve area is different in the two groups, being commissural splitting in those patients who do not get restenosis and valve stretching in those that do. In patients with an echo score > or = 10 dilatation of the mitral valve should be considered only as a palliative procedure.