Increase In Mitral Regurgitation Research Articles

"<i>Primum non nocere</i> (First, do no harm)". Case report

Diastolic myocardial dysfunction is the most important pathogenetic factor in heart failure and makes a significant contribution to hemodynamic disorders, which leads to a significant deterioration in the quality of life and prognosis of patients. This article presents a case of a patient with hypertrophic cardiomyopathy with paroxysmal atrial fibrillation and repeated pulmonary edema due to impaired diastolic function, a significant increase in mitral regurgitation and pulmonary hypertension. Given the ineffectiveness of antiarrhythmic therapy and the predicted failure of catheter ablation of the arrhythmogenic focus, the patient was scheduled for atrioventricular destruction. However, the strategy was revised to optimize the heart failure therapy, against which the tachysystole paroxysmal atrial fibrillation did not recur over the following time.

P888Left ventricular diastolic function and left atrial longitudinal function during exercise correlate with exercise capacity in patients with hypertrophic cardiomyopathy

Abstract Background The clinical course of hypertrophic cardiomyopathy (HCM) is heterogeneous and the development of heart failure (HF) is difficult to predict. Exercise echocardiography can provide information about mechanisms involved in the occurrence of HF symptoms: development of intraventricular obstruction, increase in mitral regurgitation (MR) severity, impaired left ventricular (LV) and left atrial (LA) function. Purpose To analyse the changes in LV and LA function during exercise and to identify the main correlates of exercise capacity in patients (pts) with HCM, in sinus rhythm and with normal LV ejection fraction. Methods We have prospectively enrolled 32 pts (48±17 years, 15 men) with HCM and no obstruction at rest. A symptom limited exercise echocardiogram was performed in all pts using a table ergometer. Maximum LV wall thickness (LVWT), indexed left atrial volume (LAVi), septal E', E/septal E' ratio, were measured at rest (r) and during exercise (e). Global longitudinal LV strain (GLS) and LA strain (LAɛ) were assessed by speckle tracking echocardiography at rest and during exercise. The peak LV outflow tract gradient, systolic pulmonary artery pressure (PAP), and MR degree were recorded at rest and during exercise. Exercise-related symptoms, peak exercise heart rate (HR) and exercise capacity calculated in metabolic equivalents (METs) were also recorded. Results The mean value of achieved METs was 5.9±1.4, the peak HR was 124±25 bpm, representing 72±12% of maximal HR, during a mean of 8.5±2.5 minutes of exercise. Thirteen pts developed LV gradients >30 mmHg. Fifteen pts were asymptomatic, while 17 pts reported dyspnea during exercise. There were no significant differences between pts with and without symptoms regarding: age, rE', rE/E', rGLS, rLAɛ, rMR, rPAP, LAVi, eE/e', eGLS, eMR, ePAP (p>0.05 for all). Symptomatic pts had lower values for eE' (p=0.01), eLAɛ (p=0.03) and tended to have higher values for LVWT (p=0.06) and a higher prevalence of eLV outflow tract obstruction (p=0.13) compared to asymptomatic pts. In symptomatic group of pts, E' (p=0.004), PAP (p<0.001) and GLS (p=0.04) significantly increased and LAɛ tended to decrease (p=0.18) during exercise. Age (r=−0.44, p=0.01), rE' (r=0.40, p=0.02), eE' (r=0.46, p=0.01), ePAP (r=−0.35, p=0.04) and LVWT (r=−0.32, p=0.07) significantly correlated with achieved METs in HCM pts overall. In multivariate analysis, eE' (β=0.60, 95% CI 0.122 to 0.009, p=0.003) was the only parameter independently correlated with exercise capacity (expressed in METs). Conclusions Symptomatic pts had a worse LV diastolic function (as expressed by E') and a severe LA longitudinal dysfunction (as expressed by LAɛ) during exercise. E' during exercise was the only parameter independently correlated with exercise capacity in pts with HCM. These suggest that a detailed analysis of LV and LA function during exercise could provide additional information to predict the occurrence of HF in HCM pts.

Transaortic repair of concomitant mitral insufficiency in patients with critical aortic stenosis undergoing aortic valvular replacement.

In this study, we present operation technique and outcomes of transaortic mitral valve repair in high-risk patients undergoing aortic valve replacement due to severe aortic stenosis. Between January 2005 and March 2016, a total of 11 patients (7 females, 4 males; mean age 71.2±4.1 years; range, 65 to 77 years) with severe aortic valve stenosis (aortic valve area <1 cm2 or aortic valve area index <0.6 cm2/m2) and concomitant moderate or severe mitral regurgitation (non-ischemic, regurgitant jet origin between A2-P2 portions) secondary to left ventricular dysfunction (EuroSCORE logistic score >5%, left ventricular ejection fraction <30%) who were operated were retrospectively analyzed. Aortic valve replacement and transaortic mitral edge-to-edge repair was applied to all patients. Operations were performed through sternotomy, cardiopulmonary bypass, and bicaval venous return. Transesophageal echocardiography was used to evaluate mitral valve before surgery and valve functions after surgery. Postoperative course of all patients was monitored, and postoperative complications were recorded. The mean preoperative ejection fraction was 24.5±4.1% and the mean transaortic pressure gradient was 35.8±4.8 mmHg. The mean aortic cross-clamp time was 62.09±10.1 (range, 43 to 76) min and the median cardiopulmonary bypass time was 90.1±11.9 (range, 66 to 114) min. No hospital mortality was observed. In the postoperative period, two patients experienced renal insufficiency. Hemofiltration was initiated in these patients and no dialysis was required at two weeks. One patient had postoperative atrial fibrillation and one patient had pericardial effusion leading to cardiac tamponade and this patient underwent reoperation. The patients were followed up for a mean of four years and control echocardiography didn"t detect increase in mitral regurgitation degree. Transaortic edge-to-edge mitral valve repair can be used in high-risk patients undergoing aortic valve replacement. This technique is feasible with shorter cross-clamp time and can reduce mortality and morbidity in selected high-risk patients.

Study of Effectiveness and Safety of Percutaneous Balloon Mitral Valvulotomy for Treatment of Pregnant Patients with Severe Mitral Stenosis.

In pregnant women mitral stenosis is the commonest cardiac valvular lesion. When it is present in majorly severe condition it leads to maternal and fetal morbidity and mortality. In mitral stenosis pregnancy can lead to development of heart failure. To evaluate the safety and efficacy of balloon mitral valvulotomy (BMV) in pregnant females with severe mitral stenosis. A total of 30 pregnant patients who underwent BMV were included in the study from July 2011 to November 2013. Clinical follow-up during pregnancy was done every 3 months until delivery and after delivery. The mean follow up time after BMV was 6.72±0.56 months. From the 30 pregnant females 14 (46.67%) and 16 (53.3%) patients underwent BMV during the third and second trimester of pregnancy respectively. The mean mitral valve area was 0.85+0.16 cm(2) before BMV that increased to 1.60+0.27 cm(2) (p<0.0001) immediately after BMV. Peak and mean diastolic gradients had decreased significantly within 48 hours after the procedure (p<0.001) but remained very much unchanged at 6.72 month period of follow-up. Two patients had an increase in mitral regurgitation by 2 grades. During pregnancy BMV technique is safe and effective in patients with severe mitral stenosis. This results in marked symptomatic relief along with long term maternal and fetal outcomes.

133: Impact of post-procedural aortic regurgitation on mortality after transcatheter aortic valve implantation

To clarify the impact of mild post-procedural aortic regurgitation (post-AR) on clinical outcomes. Post-procedural aortic regurgitation (post-AR) is known to be associated with poor short-mid term outcome after transcatheter aortic valve implantation (TAVI). We compared clinical outcomes in 400 consecutive TAVI recipients according to post-AR grade: none (group 1=74.8%), mild (group 2=22.2%) or moderate to severe (group 3=3.0%). The mean age was similar in the 3 groups (83.4±6.1years) as well as logistic EuroSCORE (22.5±11.4, 24.5±11.6 and 21.5±9.4%, p=0.28) and annulus size (22.0±1.8, 22.2±2.1 and 22.5±2.1 mm, p=0.53). The Edwards valve was the most frequently used in group 1 compared to group 2 and 3 (89.3, 78.7 and 83.3%, p=0.03) and the implanted valve size was similar in all groups (25.6±2.0, 25.4±2.2 and 25.5±2.2 mm respectively, p=0.69). Post-dilatation was required more frequently in group 3 (4.7, 24.1 and 50.0% respectively, p<0.01). Post-procedural increase in mitral regurgitation was in line with the post-AR grade (0.78±0.73, 1.22±0.80 and 1.89±0.78, respectively, p<0.01). Despite the absence of difference in 30-day mortality, longer-term outcome showed patients with mild AR had a significantly worse outcome compared to none (log-rank p<0.01) and better than moderate to severe (p=0.04), regardless of TAVI type and left ventricular function. Post-AR was also identified as an independent predictor for mid-long term mortality (HR1.68, 95%CI:1.21–1.44, p<0.01). Mild post-AR after TAVI is associated with worse outcome compared to none to trivial. Cautious valve selection and post-dilatation when required to avoid mild post-AR might contribute to improved clinical outcome after TAVI.

Impact of Post-Procedural Aortic Regurgitation on Mortality After Transcatheter Aortic Valve Implantation

The goal of the study was to clarify the impact of post-procedural aortic regurgitation (post-AR) grade 2/4 on clinical outcomes. Post-AR >2/4 is known to be associated with poor short- to midterm outcome after transcatheter aortic valve implantation (TAVI). We compared clinical outcomes in 400 consecutive TAVI recipients according to post-AR grade: grade 0 or 1 (group 1 = 74.8%), grade 2 (group 2 = 22.2%), or grade 3 or 4 (group 3 = 3.0%). The mean age was similar in the 3 groups (83.4 ± 6.1 years) as was the logistic EuroSCORE (22.5 ± 11.4%, 24.5 ± 11.6%, and 21.5 ± 9.4%, p = 0.28) and annulus size (22.0 ± 1.8, 22.2 ± 2.1, and 22.5 ± 2.1 mm, p = 0.53). The Edwards valve was most frequently used in group 1 compared with groups 2 and 3 (89.3%, 78.7%, and 83.3%, p = 0.03), and the implanted valve size was similar in all groups (25.6 ± 2.0, 25.4 ± 2.2, and 25.5 ± 2.2 mm, respectively, p = 0.69). Post-dilation was required more frequently in group 3 (4.7%, 24.1%, and 50.0%, respectively, p < 0.01). Post-procedural increase in mitral regurgitation was in line with the post-AR grade (0.78 ± 0.73, 1.22 ± 0.80, and 1.89 ± 0.78, respectively, p < 0.01). Despite the absence of difference in 30-day mortality, longer-term outcome was significantly poorer in patients with AR grade 2 than in those with AR grade 0 or 1 (log-rank p < 0.01), albeit better than in patients with AR grade 3 or 4 (p = 0.04), regardless of TAVI type and left ventricular function. Post-AR ≥2/4 was also identified as an independent predictor of mid- to long-term mortality (hazard ratio: 1.68, 95% confidence interval: 1.21 to 1.44, p < 0.01). Post-AR grade 2/4 after TAVI is associated with worse outcome compared with grade 0 or 1. Careful valve selection and post-dilation when required to avoid post-AR grade 2 may contribute to improved clinical outcome after TAVI.

Could exercise unveil the mystery of non-response to cardiac resynchronization therapy?

Left ventricular mechanical dyssynchrony describes the differences in the timing of contraction between different myocardial segments that are commonly observed in patients with congestive heart failure, particularly in those with depressed LV ejection fraction. Its presence varies with not only the methods of assessment, but also characteristics of the study population including the QRS duration, loading condition, severity of coronary artery disease, LV hypertrophy, and LV remodelling. Therefore, the ECG criteria of QRS width ≥120 ms adopted in the current guidelines may not be optimal for identifying patients who will benefit most from CRT or defining the presence of mechanical dyssynchrony. 6 Analysis of LV dyssynchrony is achieved by different imaging modalities such as echocardiography, from conventional M-mode and Doppler echocardiography to more advanced tissue Doppler imaging (TDI), three-dimensional echocardiography, and speckle tracking imaging, and most of the time, performed at rest. Consequently, lack of mechanical dyssynchrony has been found in about one-third of heart failure patients with QRS duration ≥120 ms. On the other hand, mechanical dyssynchrony occurs in 40‐50% of patients with a narrow QRS complex defined as ,120 ms. 7 Furthermore, numerous studies have suggested that the presence and the extent of LV mechanical dyssynchrony could be a better predictor of response to CRT than QRS duration per se. 5,8 Not until recently, the contribution of exercise to LV mechanical dyssynchrony has been investigated and exercise-induced dyssynchrony has been found to be associated with exacerbation of heart failure symptoms, an increase in mitral regurgitation, and a reduction in exercise capacity. 9‐12 Therefore, it appears that the assessment of LV mechanical dyssynchrony only at rest may not be sufficient in heart failure patients. The landmark study by Lafitte et al. 9 first described how mechanical dyssynchrony was modified by exercise in 65 consecutive patients with LV ejection fraction of ,35% and New York Heart Association class II or III symptoms. Depending on the parameter adopted for assessment and using 20% of change as a cut-off point, LV systolic dyssynchrony increased in 28‐40%, remained the same in 35‐43%, and decreased in 23‐31% of the patients during exercise. On a closer inspection, patients could be categorized into four different groups: patients without dyssynchrony at rest but induced by exercise (exercise-induced dyssynchrony), patients with dyssynchrony at rest which normalized during exercise, patients without dyssynchrony at rest as well as during exercise, and patients with dyssynchrony in both situations. The former two groups warranted further investigation to help understand the relationship with lack of response to CRT, which represented 20‐26% of the study population. In another study in 60 patients with dilated cardiomyopathy and narrow QRS complex (,120 ms), significant mechanical dyssynchrony was observed in 33.3% of patients at rest and in 58.3% during exercise. The dynamic change in standard deviations of the time to peak systolic velocity of the 12 LV segments (Ts-SD or Yu Index) as the dyssynchrony measurement between rest and exercise showed an independent positive association with the change in mitral regurgitation, and an independent inverse correlation with the change in LV stroke volume. 10 Wang et al. 11 reported the occurrence of exercise-evoked systolic dyssynchrony in 11 (33%) of 33 heart failure patients with ejection

Effectiveness of Balloon Valvuloplasty for Palliation of Mitral Stenosis After Repair of Atrioventricular Canal Defects

Closure of a mitral valve (MV) cleft, small left-sided cardiac structures, and ventricular imbalance all may contribute to mitral stenosis (MS) after repair of atrioventricular canal (AVC) defects. MV replacement is the traditional therapy but carries high risk in young children. The utility of balloon mitral valvuloplasty (BMV) in postoperative MS is not established and may offer alternative therapy or palliation. Since 1996, 10 patients with repaired AVC defects have undergone BMV at a median age of 2.5 years (range 8 months to 14 years), a median of 2 years after AVC repair. At catheterization, the median value of mean MS gradients was 16 mm Hg (range 12 to 22) and was reduced by 34% after BMV. Before BMV, there was mild mitral regurgitation in 9 of 10 patients, which increased to severe in 1 patient. All patients were alive at follow-up (median 5.4 years). Repeat BMV was performed in 4 patients, 10 weeks to 18 months after initial BMV. One patient underwent surgical valvuloplasty; 3 underwent MV replacement 2, 3, and 28 months after BMV. In the 6 patients (60%) with a native MV at most recent follow-up (median 3.2 years), the mean Doppler MS gradient was 9 mm Hg, the median weight had doubled, and weight percentile had increased significantly. In conclusion, BMV provides relief of MS in most patients with repaired AVC defects; marked increases in mitral regurgitation are uncommon. Because BMV can incompletely relieve obstruction and increase mitral regurgitation, it will not be definitive in most patients but will usually delay MV replacement to accommodate a larger prosthesis.

Cardiotoxicity in Patients with Multiple Myeloma Treated with Tandem Autologous Hematopoetic Stem Cell Transplantation.

BACKGROUND. Tandem autologous hemopoetic stem cell transplantation (HSCT) was recognised as effective treatment modality in patients with multiple myeloma (MM). During the treatment period patients are treated with high doses of cyclophosphamide followed twice with high doses of melphalan. There are scant data, if any, regarding potential cardiotoxic side effects of this treatment modality. METHODS. We included 30 patients with newly diagnosed multiple myeloma. After they were treated with three cycles of chemotherapy, they received high doses of cyclophosphamide 4 mg/m2 (cycle CY), followed by two autologous tandem HSCT, where patients received melphalan 200 mg/m2 (cycle MEL I and cycle MEL II). During each fifteen-day treatment period blood was routinely controlled for biochemical parameters troponin I (TnI), brain natriiuretic peptide (BNP) and endothelin-1 (ET-1) at six time points. All patients underwent conventional and tissue Doppler echocardiographic examination before treatment with cyclophosphamide (Eho 0), before cycle MEL I (Eho 1), before cycle MEL II (Eho 2) and three months after completion of the therapy (Eho 3). RESULTS. None of the patients developed clinical signs of heart insufficiency. Highest TnI values in all three cycles of chemotherapy were observed on the eighth, eleventh and fifteenth day of treatment. But all TnI values in patients were lower than 0.04 μg/L. During all three cycles we noticed a significant increase in BNP values compared with the basal values and values on day one after treatment with cyclophosphamide and melphalan (CY: P = 0.0001, MEL I: P = 0.001, MEL II: P= 0.001). In cycle CY this was also the highest BNP value (0.517 ± 0.391 μg/L). The maximum BNP values in cycles MEL I and MEL II were noticed on day four after chemotherapy (MEL I 0.376 ± 0.418 μg/L; MEL II 0.363 ± 0.379 μg/L). The highest ET-1 values in all three cycles were noticed on day one after chemotherapy (CY 1.146 ± 1.313 ng/L; MEL I 1.054 ± 2.242 ng/L; MEL II 0.618 ± 0.539 ng/L). We observed a significant increase in ET-1 values compared with the basal values only in cycle MEL II (P = 0.003). Concerning the parameters of diastolic left ventricular function, the duration of wave a in Doppler pulmonary vein flow signal significantly increased compared with it's basal value (Eho 0/Eho 1: P = 0.008, Eho 0/Eho 3; P = 0.026). The ratio A/a in flow velocities significantly decreased with cycles of chemotherapy (Eho 0/Eho 1: P = 0.002, Eho 0/Eho 3: P < 0.0001). Early diastolic tissue Doppler velocities (Em) decreased significantly within individual cycles of chemotherapy (P = 0.006). After the treatment a significant increase in mitral regurgitation was observed (Eho 0/Eho 3; P = 0.003). Pericardial effusion was observed in six patients (20.6%). CONCLUSIONS. Treatment of MM patients with autologous tandem HSCT is cardiotoxic. Patients did not develop clinical signs of overt heart failure and normal TnI values excluded myocardial necrosis. On the other hand, increased plasma BNP and ET-1 levels confirm transient neurohormonal activation of heart failure, likely in combination with toxic endothelial damage. Doppler echocardiography studies prove worsening of the left ventricular diastolic function and appearance of functional mitral regurgitation. The age of the patients has no influence on the clinical, laboratory and echocardiography parameters of cardiotoxicity.

Effect of Dynamic Left Ventricular Dyssynchrony on Dynamic Mitral Regurgitation in Patients With Heart Failure Due to Coronary Artery Disease

In patients with heart failure, exercise-induced increases in mitral regurgitation (MR), which convey a poor prognosis, are related to the dynamic distortion of mitral valve geometry. It was hypothesized that dynamic MR may also be related to intermittent changes in left ventricular synchronicity during exercise.

Increased Mitral Valve Regurgitation and Myocardial Hypertrophy in Two Dogs With Long-Term Pimobendan Therapy

The aim of this article is to describe original adverse effects in two dogs chronically treated with the inodilator pimobendan. We report a German shepherd (i.e., dog 1) and a poodle (i.e., dog 2) that were referred to our cardiology unit after receiving pimobendan for 10 and 5 mo, respectively. In both dogs, conventional echo-Doppler examination demonstrated mitral valve regurgitation and myocardial hypertrophy. Tissue Doppler imaging (TDI) was performed in the first case and revealed an abnormal relaxation phase. After the first examination, pimobendan administration was stopped in both cases and dogs were re-examined 3 and 1 mo later, respectively. Mitral valve regurgitation assessed by echocardiography decreased in both dogs, and the systolic heart murmur disappeared in dog 1. Importantly, most echocardiographic and TDI parameters tended to normalize in dog 1, suggesting, at least partial reversal of both myocardial hypertrophy and relaxation abnormality produced during inodilator therapy. This is the first report to describe an increase in mitral regurgitation under clinical conditions in dogs treated with pimobendan. We also suggest that pimobendan may induce ventricular hypertrophy. However, prospective studies are needed to confirm this observation.

Effect of fenfluramine-derivative diet pills on cardiac valves: A meta-analysis of observational studies

Background Fenfluramine-derivative diet pills were withdrawn from the market in 1997 because of an association with valvular regurgitation, but subsequent estimates of the prevalence of this condition have varied widely. We systematically reviewed evidence regarding the prevalence of valvular disease after fenfluramine exposure. Methods We searched multiple databases with multiple search terms. Conference proceedings from 1997 onward were searched by index. Authors of eligible studies were contacted to identify unpublished works. Selection criteria were liberally determined. Ten of the identified 11 articles met these criteria. Reviewers assessed the studies' methodologic quality by use of a standard form to evaluate selection, attrition, performance, and detection bias. The studies were analyzed in 2 groups on the basis of length of exposure (<90 days or >90 days). The Mantel-Haenszel method was used to summarize data. Quantitative and qualitative tests for heterogeneity were performed. Tests for publication bias were also done. Results Tests for heterogeneity were nonsignificant after removing 1 outlier trial. The pooled prevalence of valvular regurgitation meeting Food and Drug Administration criteria (at least mild aortic regurgitation or at least moderate mitral regurgitation) among patients treated for >90 days was 12.0% compared with 5.9% for the unexposed group (prevalence odds ratio 2.2, 95% CI 1.7-2.7). The combined analyses also identified a small but statistically significant increase in mitral regurgitation not previously identified by individual studies (exposed 3.5%, unexposed 1.8%, prevalence odds ratio 1.6, 95% CI 1.05-2.3). Among patients exposed for <90 days, a trend toward more regurgitation was not statistically significant by either combined Food and Drug Administration criteria (exposed 6.8%, unexposed 5.8%, prevalence odds ratio 1.4, 95% CI 0.8-2.4) or by individual valve. Conclusions These data indicate that fenfluramine-associated valvular regurgitation is less common than initially reported, but still present in 1 of 8 patients treated for >90 days. (Am Heart J 2002;144:1065-73.)

Technique and Results of Percutaneous Mitral Valvuloplasty with the Multi-Track System

The Multi-Track System is a simplified double-balloon technique for percutaneous mitral valvuloplasty. Here we describe the technique and report the results obtained using it. The Multi-Track catheter has a short distal tip for connection to the guidewire. This leaves the rest of guidewire free to receive other catheters. Various catheters can be introduced over the same guidewire. The balloons are introduced one after the other allowing a smaller size of vascular access and transseptal passage. Furthermore, simultaneous pressure measurements in the left atrium and left ventricle are possible through a simple venous access, allowing avoidance of arterial puncture. We used this technique worldwide between June 1994 and February 2000 for the treatment of 153 patients with mitral stenosis worldwide. In 12 cases, the procedure was done using the exclusive venous approach. The mean mitral valve area increased from 0.75 ± 0.22 to 2 ± 0.33 cm2and the mean left atrial pressure dropped from 27 ± 8 to 11 ± 4 mmHg. Four patients had a significant increase in mitral regurgitation, requiring surgical treatment in two patients. There was no mortality. The Multi-Track system is a valid user-friendly and cost-effective alternative for the treatment of mitral stenosis. It is a rapid and effective procedure associated with low risks.

Update on Percutaneous Mechanical Mitral Commissurotomy

A reusable metallic valvotomy device has been developed with the goals of improving the results of percutaneous mitral valvotomy and increasing the cost‐effectiveness of the procedure. The device consists of a detachable and reusable metallic dilator with two articulated bars screwed at the distal end of a catheter. Using transseptal catheterization, the device is placed across the valve over a traction guidewire and then opened gradually by means of pliers up to a maximum of 40 mm. To date, the device was used in 168 patients with a broad spectrum of mitral valve disease. The procedure was successful in 95% of cases and resulted in an increase in mitral valve area from 1.01 ± 0.8 to 2.20 ± 0.7 cm2. No increase in mitral regurgitation was noted in 87% of cases. Bilateral splitting of the commissures was observed in 89%. Complications included the following: 2 severe mitral regurgitations (one requiring surgery), 1 pericardial tamponade, 1 transient cerebrovascular embolic event. The maximum number of consecutive patients treated with the same device was 35. The results obtained are at least comparable to those of current balloon techniques and confirm the possibility of safe multiple reuses of the device after sterilization.

Immediate and Long-Term Results of Percutaneous Inoue Balloon Mitral Commissurotomy With Use of a Simple Height-Derived Derived Balloon Sizing Method for the Stepwise Dilation Technique

To assess the short- and long-term efficacy of Inoue balloon percutaneous transvenous mitral commissurotomy (PTMC) with use of our simple balloon sizing method based on patient height. Data from 105 consecutive patients with symptomatic mitral stenosis who underwent 107 PTMC procedures between October 1991 and April 1995 at our hospital were analyzed. All PTMC procedures were successfully completed with no instances of cardiac perforation, systemic embolism, severe mitral regurgitation (grade 3 or more angiographically), or death. The mean mitral valve area increased from 0.8 +/- 0.2 cm2 to 1.7 +/- 0.4 cm2 (P = 0.0001), as assessed echocardiographically. Optimal results -- defined as an improvement in valve area of 50% or more or a final valve area of 1.5 cm2 or more without significant mitral regurgitation (an increase in mitral regurgitation of two or more grades or a final regurgitation of grade 3 or more) -- were obtained in 96% of patients. At a mean follow-up interval of 20 months, symptomatic benefit was maintained in 97% of patients. Echocardiographic evidence of restenosis (loss of more than 50% initial gain in valve area, a valve area of less than 1.5 cm2, or both) was noted in 9.8%. Inoue balloon PTMC with use of our simple balloon sizing method yielded excellent short- and long-term results in terms of mitral valve enlargement and sustained symptomatic benefit without the creation of severe mitral regurgitation.

Percutaneous transvenous mitral commissurotomy in 390 cases using the Inoue balloon catheter

Percutaneous transvenous mitral commissurotomy using the Inoue technique was performed in 390 cases of rheumatic mitral stenosis. There were 220 (56%) females and 170 (44%) males. The age range was 9–47 years [mean ± S.D., 26 ± 14) and all were symptomatic (New York Heart Association (NYHA) class II in 23 (6%); class III in 280 (72%); and class IV in 87 (22%) patients]. Mitral valve area increased from 0.6 ± 0.4 to 2 ± 0.7 cm 2, mean transmitral gradients decreased from 26 ± 8 to 5 ± 3 mmHg and cardiac index improved from 2.2 ± 0.8 to 3.0 ± 0.7 l/min/m 2 ( P < 0.001). There were no procedure related deaths. An increase in mitral regurgitation by one grade was observed in 40 (10%) cases, with 8 (2%) cases developing severe mitral regurgitation. Oximetry evidence of left to right atrial shunt (Q p/Q s ≥ 1.5:1) was observed in 11 (3%) patients. Four (1.0%) patients developed cardiac tamponade, none had thromboembolism. Follow-up of 290 cases at 26 ± 5 weeks showed persistent improvement in clinical (NYHA class I in 98%) and echocardiographic mitral valve area. Percutaneous transvenous mitral commissurotomy is safe, easy to perform and provides excellent clinical and hemodynamic benefit in the majority of cases.

Influence of subvalvular fibrosis on results and complications of percutaneous mitral commissurotomy with use of the Inoue balloon

In 136 consecutive patients who underwent percutaneous transvenous mitral commissurotomy (PTMC) with use of the single rubber-nylon (Inoue) balloon Inoue ballon angiographically analyzed subvalvular fibrosis was assessed retrospectively with regard to results and complications. There were 53 males and 83 females, with a mean age of 22 ± 11 years (range 10 to 48 years). For the entire group, mitral valve area increased from 0.7 ± 0.3 to 2.1 ± 0.6 cm 2 ( p < 0.001). Valve area increased from 0.7 ± 0.12 to 1.8 ± 0.14 cm 2 in patients with severe subvalvular fibrosis (n = 55) and from 0.8 ± 0.11 to 1.9 ± 0.12 cm 2 in cases with mild to moderate subvalvular fibrosis (n = 80; p = NS). The number of patients with 2+ or greater increase in mitral regurgitation was not different between the two groups (6% vs 5.5%, p = NS). None of the patients required mitral valve replacement immediately after PTMC. We conclude that, with use of the Inoue balloon, PTMC can be successfully performed in patients with severe subvalvular fibrosis.

Balloon valvotomy for mitral restenosis after open or closed surgical commissurotomy

Balloon mitral valvotomy was performed in 48 patients (Group I) with mitral restenosis following prior surgical commissurotomy 3–21 years previously. Their results were compared with those of balloon valvotomy in 302 patients without prior commissurotomy (Group II). The procedure was successful in 91.7% of Group I. The mitral valve area, cardiac output, mitral valve gradient, mean left atrial and pulmonary arterial pressures significantly improved following valvotomy (all P < 0.001) in Group I and similar results were obtained in Group II. A comparison of the absolute and percentage change in the mitral valve area following valvotomy amongst the two groups revealed no significant difference ( P = N.S.). The baseline clinical characteristics in both the groups were similar except for a higher echocardiographic score (8.64 ± 1.5 vs. 7 ± 1.7; P < 0.005) in Group I. Despite the high echo score, achievement of an ‘optimal’ result and occurrence of postprocedural mitral regurgitation were similar in both groups. The complications included systemic embolus in one patient and increase in mitral regurgitation to ≥ 2+ in 2. There were no deaths. Balloon valvotomy for mitral restenosis following surgical commissurotomy is safe, effective and produces clinical and hemodynamic results comparable to those in unoperated cases.

Transesophageal echocardiography in the diagnosis of flail tricuspid valve

more.3 Recently Roth et al8 found in a larger sample that effective balloon dilating diameter corrected by body surface area was the only predictor of the increase in mitral regurgitation after valvotomy. In the present study we did not find any relationship between asymmetric commissural involvement and the increase in mitral regurgitation. The absence of these complications reaffirms the safety of performing this procedure in patients with asymmetric commissural disease. In conclusion, asymmetric deformity of the mitral valve does not negatively influence the outcome after percutaneous balloon mitral valvotomy.

Comparison of lnoue single-balloon versus double-balloon technique for percutaneous mitral valvotomy

The results of percutaneous mitral valvotomy by means of the lnoue single-balloon (N = 85, group 1) and the double-balloon (N = 322, group 2) techniques were compared in a nonrandomized study. The groups were not significantly different with regard to age, sex, calcification, or hemodynamic values before percutaneous mitral valvotomy. After percutaneous mitral valvotomy, patients in both groups had significant hemodynamic and clinical improvement. The increases in mitral valve area and cardiac output and the decreases in mitral valve gradient, mean pulmonary artery pressure, and mean left atrial pressure were greater in group 2. Mitral valve area determined by the Gorlin method increased 191% in group 2 and 106% in group 1; Doppler-determined mitral valve area increased 133% in group 2 and 98% in group 1. Optimal results were achieved in 93% of the patients in group 2 and 76% in group 1 ( p ≤ 0.0001). In group 1, 6% of patients had a left-to-right shunt as shown by angiography versus 14% in group 2 ( p ≤ 0.05). In group 2, 46% of patients had at least a 1 + increase in mitral regurgitation versus 52% in group 1. Among the patients who had an increase in mitral regurgitation, 36% of those in group 1 versus 9% in group 2 had a 2+ or more increase ( p ≤ 0.001). The mean balloon diameter to anulus ratio was larger in group 2, and the larger the balloon diameter to anulus ratio, the greater the increase in mitral valve area. Long-term follow-up will be needed to determine whether or not the immediate hemodynamic superiority of the double-balloon technique is clinically important.