Balloon Mitral Commissurotomy Research Articles

Validation of New Real-Time Three-Dimensional Transesophageal Echocardiographic Scoring System in Prediction of Immediate and Long-term Outcome After Percutaneous Balloon Mitral Valvuloplasty

Dear Editor,The guidelines recommend percutaneous mitral balloon commissurotomy (PMBC) as the first choice therapy for symptomatic patients with moderate or severe mitral stenosis (MS) with favorable valve morphology and for asymptomatic MS patients with pulmonary hypertension (1). Echocardiography is the main diagnostic imaging method for assessing mitral valve stenosis and evaluating the severity and hemodynamic consequences of MS as well as valve morphology and disease extension (2). The main predictor of successful BMV is mitral valve morphology. Therefore, the MV scoring system using echocardiography is very important. Several two-dimensional echocardiographic scoring systems have been proposed to evaluate MV morphology, the severity of which is related to immediate and long-term outcome (3). Most cardiologists use the Wilkins score for evaluation of MV anatomy. Although, none of the available 2DE scores have not been shown to be superior to any of the other scores (4). The evaluation of the MV Wilkins score depends on the assessment of four parameters, which include: leaflets mobility, thickness, calcification, and subvalvular involvement. Each parameter is given a score of 1-4 and by calculating its sum, the total score of 1-16/16 (mild involvement = 1-4/16, moderate involvement = 5-8/16, and severe involvement > 8/16) is obtained (3). The ideal echocardiographic scoring system should have the following characteristics:Quantitative and qualitative evaluation of each component of the MV apparatus separately to determine the deformity in a specific portionThe inclusion of all the points that have been proven through a large study affects the BMV resultEasy to use and interpretable by most cardiologists at a reasonable timeHigh reliability and reproducibility (4)In recent years, real-time three-dimensional echocardiography technology has evolved rapidly. RT3DE provides detailed morphologic display and analysis of the mitral valve structure. Improving the RT3DE probe technology, especially transesophageal probes, highlights the need to introduce a RT3DE scoring system (5). Anwar et al. introduced the first scoring system using real-time three-dimensional transthoracic echocardiography (RT3D-TTE) in patients with mitral valve stenosis candidate BMV, and compared the new score with the Wilkins score in predicting outcome after BMV. In the new RT3DE score, each leaflet was divided into three scallops (anterolateral A1-P1, middle A2-P2, and posteromedial A3-P3) and each scallop was scored separately for thickness, calcification, and mobility, as follows: 0 for normal thickness and mobility, 1 for abnormal thickness and restricted mobility, and for scoring calcification: 0 for the absence of calcification, 1 for calcification of middle scallop (A2 or P2) and 2 if there is calcification of commissural scallops (A1, A3-P1, P3). For scoring subvalvular apparatus, the anterior and posterior chordae were scored at three levels as follows: proximal (valve level), middle, and distal (papillary muscle level). Each level was scored separately for thickness and separation in between as follows: 0 for normal thickness, 1 for abnormal thickness, also 0 in case of normal chordal separation (distance in between >5 mm), 1 in case of partial separation (distance in between <5 mm) and 2 in case of absence separation. From the sum of these points, a total score of 0-31/31 (mild MV involvement <8, moderate MV involvement 8-13, and severe MV involvement >14) is obtained (6). 3D-Anwar score is complex and time consuming. This is due to the many anatomical and morphological components to achieve an accurate assessment. The available 3D score is highly selective for optimal BMV result, which leads to more patients being referred for surgery (5). So we decided to introduce a three-dimensional transesophageal (3D-TEE) echocardiographic scoring system that meets the criteria of an ideal echocardiographic scoring system, and evaluate the validity of the new score in predicting the immediate and long-term outcome of patients after BMV. We also believe that many studies are needed to achieve an ideal RT3DE scoring system.

Reverse remodeling of the atria in patients with rheumatic mitral stenosis: impact of balloon mitral commissurotomy plus atrial fibrillation ablation

Abstract Introduction Chronic Atrial stretch is an important determinant for atrial fibrillation (AF) in patients with rheumatic mitral stenosis (RMS). Purpose We analysed the effect of balloon mitral commissurotomy (BMC) plus atrial fibrillation ablation on the long-term occurrence of AF as compared to isolated BMC. Methods We prospectively included 20 patients with severe RMS undergoing BMC+AF ablation (Intervention) and compared it with a retrospective sample of 53 RMS patients that underwent BMC (Control). AF ablation consisted in pulmonary vein isolation and driver ablation identified using intracardiac basket mapping. We followed patients for 1 year after the procedure in both groups. Clinical values were evaluated in both groups. Propensity score matching was computed in order to evaluate the effect of the intervention and to analyse the impact of clinical properties of each group. Results At baseline, there were no statistical differences in gender (90% vs. 85%) and mitral valve area (1.2±0.18 vs. 1.17±0.18 cm2) between intervention and control groups, respectively. In contrast, there were differences in age (65±12 vs. 72±12; p=0.01) and AF incidence prior to the procedure (90% vs. 62%; p=0.001) between intervention and control groups, respectively. Patients undergoing AF ablation underwent successful pulmonary vein isolation in all cases and driver ablation at sites located in the right atrium (RA) in 7 (35%) patients. Median dominant frequency was significantly higher in the right atrium (DF RA 4.9±0.6 vs. DF LA 3.9±0.7 Hz; p=0.003) prior the intervention. After the intervention, it was significantly reduced only in the left atrium (LA) (DF RA 4.5±1 vs. DF LA 3.2±0.6 Hz; p=0.02 for Pre vs. Post DF LA). Three (15%) patients converted to sinus rhythm during ablation, the remaining were cardioverted. After 1-year follow-up, the proportion of patients in sinus rhythm was significantly higher in patients undergoing BMC+AF (90%) vs. isolated BMC (45%; p<0.001) (Graph). In the isolated BMC group, 4 patients converted to sinus rhythm and 1 patient in sinus rhythm prior to the procedure converted to AF at 1-year. Conclusion This observational study demonstrates that the combination of BMC+AF ablation significantly increses the proportion of patients in sinus rhythm at 1-year as compared to isolated BMC. Reverse remodelling of the atrial substrate following isolated BMC also converted to sinus rhythm a small proportion of patients with persistent AF at baseline. Thus, although reversal of atrial stretch changes by BMC could potentially terminate AF in some patients, the combined intervention with catheter ablation will successfully maintain sinus rhythm in the majority of patients in the study. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): FIS by Instituto de Salud Carlos III

Novel Prognostic Score for Immediate and Late Success After Percutaneous Mitral Balloon Commissurotomy in Patients With Mitral Stenosis.

Percutaneous mitral balloon commissurotomy (PMBC) remains the preferred treatment for patients with severe symptomatic rheumatic mitral stenosis (MS) and suitable anatomy. The objective of this study was to propose a new score for the prediction of immediate and late success. This is a single-center, retrospective analysis of all 1582 patients with severe mitral stenosis who underwent PMBC from August 1987 to July 2010. The composite outcome was cardiovascular death, new PMBC, or mitral valve repair surgery up to 24 years of follow-up. Mean patient age was 36.8 ± 12.9 years, most (86.4%) were female, and Wilkins score was between 9-11 in 49.1% of patients. In the multivariate analysis, the predictors of immediate success were age (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.96-0.99; P=.01), left atrium size (OR, 0.96; 95% CI, 0.93-0.99; P=.01), mean preprocedure mitral gradient (OR, 0.93; 95% CI, 0.89-0.96; P<.001), intermediate Wilkins score 9-11 (OR, 0.62; 95% CI, 0.40-0.94; P=.02), and high Wilkins score ≥12 (OR, 0.35; 95% CI, 0.16-0.76; P<.01). For prediction of late events, age (hazard ratio [HR], 0.98; 95% CI, 0.97-0.98; P<.001), New York Heart Association class III-IV (HR, 1.50; 95% CI, 1.18-1.92; P<.001), left atrium size (HR, 1.02; 95% CI, 1.02-0.04; P<.01), and high Wilkins score ≥12 (HR, 2.02; 95% CI, 1.30-3.15; P<.01) were significant. Two nomograms were developed using significant predictors from the model. In this large population, not only the Wilkins score, but also clinical and hemodynamic features, seem to be relevant in predicting immediate and late success for patients with rheumatic MS who underwent PMBC.

The Outcome of Percutaneous Mitral Balloon Commissurotomy (PMBC) in Pregnant Women with Mitral Stenosis: An Evidence Based Study

Abstract&#x0D; Objective: To review the outcome of percutaneous mitral balloon commissurotomy (PMBC) both to maternal and neonatal.&#x0D; Methods: The search was conducted on Pubmed®, Cochrane Library®, and Ovid® using MeSH. Critical appraisal determining the validity, importance, and applicability (VIA) was conducted by two independent authors.&#x0D; Results: Several studies showed that performing the PMBC had good outcome for pregnant women functional class based on NYHA. Most of them decreased from NYHA III/IV to I/II. For delivery outcome, all studies concluded that more than 80% pregnant women with mitral stenosis undergoing PMBC delivered at term, and no congenital anomalies found.&#x0D; Conclusion: Percutaneous mitral balloon commissurotomy for pregnant women with severe MS is safe during pregnancy.&#x0D; Keywords: mitral stenosis, outcome, percutaneous mitral balloon commissurotomy, pregnancy,&#x0D; &#x0D; Abstrak&#x0D; Tujuan: Mengulas luaran komisurotomi balon mitral perkutan (KBMP) baik pada maternal maupun neonatus.&#x0D; Metode: Pencarian dilakukan melalui Pubmed®, Cochrane Library®, dan Ovid® menggunakan MeSH. Telaah kristis dilakukan oleh 2 penulis independen berdasarkan validitas, kepentingan, dan aplikabilitas.&#x0D; Hasil: Beberapa studi memperlihatkan KBMP memiliki luaran yang baik di kalangan perempuan hamil berdasarkan kelas fungsional NYHA. Kebanyakan mereka mengalami penurunan NYHA dari III/IV menjadi I/II. Untuk luaran persalinan, seluruh studi menyimpulkan lebih dari 80% perempuan dengan mitral stenosis yang menjalani pembedahan KBMP melahirkan pada usia term dan tidak ditemukan kelainan.&#x0D; Kesimpulan: KBMP aman dilakukan pada perempuan hamil dengan mitral stenosis berat.&#x0D; Kata kunci: kehamilan, komisurotomibalon mitral perkutan, luaran, stenosis mitral

Outcomes in pregnant women with rheumatic mitral valve disease after percutaneous mitral balloon commissurotomy

In developing countries, mitral stenosis (MS) is the most common valvular heart disease revealed by pregnancy. Since cardiac surgery is very risky in this case, percutaneous mitral balloon commissurotomy (PMC) is currently the treatment of choice. We aimed to evaluate the immediate, medium and long-term results of PMC in pregnant women with severe MS. This was a retrospective study that included 20 pregnant women suffering from severe MS, hospitalized in the cardiology department of a tertiary care center, and treated by PMC during last two decades. Mean patients age was 31.5 ± 4.6 years. The PMC was performed on average 27.5 ± 1.8 weeks of pregnancy. Functional improvement was observed immediately after successful PMC. Mitral valve area increased from 1.01 ± 0.1 cm 2 averaged to 1.89 ± 0.3 cm 2 ( P < 0.01). Mean transmitral gradient decreased from 17.9 ± 5.8 mm Hg to 8.05 ± 4.3 mm Hg ( P < 0.01). Systolic pulmonary arterial pressure decreased from 64.85 ± 16.4 mm Hg to 39.15 ± 13.15 mm Hg ( P < 0.01). Mitral regurgitation (MR) increased in nine cases and appeared in eight cases. We noticed no severe MR during the procedure in all cases. Seventeen patients delivered at term. Newborns were all healthy. Four of them had a low birth weight. On the long term follow-up (133.35 ± 77.3 months), five patients had mitral restenosis, one patient underwent a second PMC and the four other patients had a surgical valve replacement. Predictive factors of restenosis were Wilkins score ≥ 8 and partial or absent commissural opening during procedure. These results were comparable to those observed in a population of non-pregnant women who underwent PMC during the same period. It is clear that PMC is an effective technique in the management of MS during pregnancy. The ultimate goal is to improve the hemodynamic situation of the patient in order to pursue the pregnancy and to get better conditions for childbirth.

P4357Implementation of interactive mixed reality display of three-dimensional echocardiography during percutaneous structural interventions

Abstract Background Three-dimensional (3D) echocardiographic data acquired from transesophageal (TEE) window are commonly used in planning and during percutaneous structural cardiac interventions (PSCI). Purpose We hypothesized that innovative, interactive mixed reality display can be integrated with procedural PSCI workflow to improve perception and interpretation of 3D data representing cardiac anatomy. Methods 3D TEE datasets were acquired before, during and after the completion of PSCI in 8 patients (occluders: 2 atrial appendage, 2 patent foramen ovale and 3 atrial septal implantations and percutaneous mitral commissurotomy). 30 Carthesian DICOM files were used to test the feasibility of mixed reality with commercially available head-mounted device (overlying hologram of 3D TEE data onto real-world view) as display for the interventional or imaging operator. Dedicated software was used for files conversion and 3D rendering of data to display device (in 1 case real-time Wi-Fi streaming from echocardiograph) and spatial manipulation of hologram during PSCI. Custom viewer was used to perform volume rendering and adjustment (cropping, transparency and shading control). Results Pre- and intraprocedural 3D TEE was performed in all 8 patients (5 women, age 40–83). Thirty selected 3DTEE datasets were successfully transferred and displayed in mixed reality head-mounted device as a holographic image overlying the real world view. The analysis was performed both before and during the procedure and compared with flatscreen 2-D display of the echocardiograph. In one case, real-time data transfer was successfully implemented during mitral balloon commissurotomy. The quality of visualization was judged as good without diagnostic content loss in all (100%) datasets. Both target structures and additional anatomical details were clearly presented including fenestrations of atrial septal defect, prominent Eustachian valve and earlier cardiac implants. Volume rendered views were touchlessly manipulated and displayed with a selection of intensity windows, transfer functions, and filters. Detail display was judged comparable to current 2-D volume-rendering on commercial workstations and touchless user interface - comfortable for optimization of views during PSCI. Conclusions Mixed reality display using a commercially available head-mounted device can be successfully integrated with preparation and execution of PSCI. The benefits of this solution include touchless image control and unobstructed real world viewing facilitating intraprocedural use, thus showing superiority over virtual or enhanced reality solutions. Expected progress includes integration of color flow data and optimization of real-time streaming option.

First-in-man experience with real-time holographic mixed reality display of three-dimensional echocardiography during structural intervention: balloon mitral commissurotomy.

First-in-man experience with real-time holographic mixed reality display of three-dimensional echocardiography during structural intervention: balloon mitral commissurotomy.

Rheumatic Mitral Valve Stenosis: Diagnosis and Treatment Options.

This review provides an update on rheumatic mitral stenosis. Acute rheumatic fever (RF), the sequela of group A β-hemolytic streptococcal infection, is the major etiology for mitral stenosis (MS). While the incidence of acute RF in the Western world had substantially declined over the past five decades, this trend is reversing due to immigration from non-industrialized countries where rheumatic heart disease (RHD) is higher. Pre-procedural evaluation for treatment of MS using a multimodality approach with 2D and 3D transthoracic and transesophageal echo, stress echo, cardiac CT scanning, and cardiac MRI as well as hemodynamic assessment by cardiac catheterization is discussed. The current methods of percutaneous mitral balloon commissurotomy (PMBC) and surgery are also discussed. New data on long-term follow-up after PMBC is also presented. For severe rheumatic MS, medical therapy is ineffective and definitive therapy entails PMBC in patients with suitable morphological mitral valve (MV) characteristics, or surgery. As procedural outcomes depend heavily on appropriate case selection, definitive imaging and interpretation are crucial. It is also important to understand the indications as well as morphological MV characteristics to identify the appropriate treatment with PMBC or surgery.

Immediate Outcome and Predictors of Percutaneous Mitral Balloon Commissurotomy: A 5 Years Experience in Cardiac Center Ethiopia

Percutaneous mitral balloon commissurotomy (PMBC) is the treatment of choice for rheumatic mitral stenosis with favorable anatomy and prevents complications inherent to a surgical procedure, while maintaining effectiveness. In view of this, we examined the immediate outcome and its predictors of patients undergoing PMBC in our Cardiac Center and availed evidence based information for future use of the treatment in Ethiopia. A retrospective data analysis of 330 patients with symptomatic severe mitral stenosis treated with PMBC using Inoue balloon in the cardiac center Ethiopia from 2014 to 2018 were assessed for their clinical outcome for those who presented for the first time in our cardiac center, Addis Ababa. Demographic, clinical, echocardiographic and hemodynamic data of all patients with symptomatic severe mitral stenosis were collected and analyzed. Of the 330 PMBC performed during the 5 years in the center, the majority had successful procedure (97.88%) and optimal result (92.42%). Twenty four (7.2%) had complications of which 7 (2.1%) had failed procedure and 9 (2.7%) marked mitral regurgitation. Atrial fibrillation was observed in 67 (20.3%). The mean mitral valve score (MVS) was 7.3± 1.35 ranged from 4 to 13. A significant association of immediate outcome was observed with atrial fibrillation (AOR=4.41; 95% CI=1.51 to 12.89) and high mitral valve total Wilkins score (AOR=0.25; 95% CI 0.09 to 0.70). The major predictors identified for poor outcome are atrial fibrillation and MVS. Percutaneous mitral balloon commissurotomy is a safe procedure with excellent immediate results signifying that it is a treatment of choice for heterogeneous group of patients with rheumatic mitral stenosis.

Percutaneous transmitral balloon commissurotomy using a single balloon with arteriovenous loop stabilisation: an alternative when there is no Inoue balloon.

SummaryBackgroundThe Inoue balloon technique is the standard technique for mitral valve balloon commissurotomy at this stage. However, the hardware for this technique is expensive and may not always be available in resource-limited settings. ObjectivesThis article reports our experience with percutaneous transmitral balloon commissurotomy using a single balloon (Nucleus) with arteriovenous loop stabilisation.MethodsEleven young patients, aged 12–26 years and weighing 23–48 kg, underwent transmitral balloon commissurotomy using the described technique at our centre from April to May 2014. ResultsMean fluoroscopy time was 22.6 ± 6.4 min (18.5– 30.0). Mean transmitral gradient decreased from 24.1 ± 5.9 (16–35) to 6.6 ± 3.8 (3–14) mmHg, as measured on transoesophageal echocardiography. Mean mitral valve area increased from 0.69 ± 0.13 cm2 (range 0.5–0.9) before dilation to 1.44 ± 0.25 cm2 (1.1–1.9) after dilation (p < 0.001). Mean estimated pulmonary artery systolic pressure decreased from 110.0 ± 35 mmHg (75–170) before dilation to 28.0 ± 14.4 mmHg (range 10–60) after dilation.ConclusionOur modified Nucleus balloon technique for mitral valve dilation in young patients with mitral stenosis is effective and safe. The technique differs from other over-thewire techniques in that it avoids placing stiff wire in the left ventricle. It also offers better balloon stability and control owing to the arteriovenous loop. This technique may be easier for use by paediatric interventionists who might not be familiar with the Inoue balloon technique.

Interventional Echocardiography of the MV: What the Interventionalist Wants to Know.

The past 2 decades have seen a proliferation of transcatheter mitral valve (MV) therapies, which are less invasive and distinct from surgical MV repair or replacement. The commonly used MV transcatheter therapies include (1) percutaneous mitral balloon commissurotomy (PMBC) for rheumatic mitral stenosis; (2) edge-to-edge repair with the MitraClip for mitral regurgitation; (3) valve-in-valve implantation in bioprosthetic MV, native MV, or mitral ring; and (4) closure of paravalvular leaks (PVLs). This article will focus on the use of echocardiography in the diagnosis, patient selection, procedural guidance, and postprocedural follow-up for PMBC, with notes on the role of transesophageal echocardiography in transcatheter interventions for prosthetic valve degeneration and PVL closure.

A new simple score to predict late outcome of balloon mitral commissurotomy

Balloon mitral commissurotomy (BMC) has become widely accepted as the treatment of choice for mitral stenosis in patients with favorable anatomy, but few tools are available to predict its long-term outcome. We sought to determine a simple score to predict late outcome of BMC in patients with mitral stenosis. Late results of BMC were assessed in 1035 consecutive patients at our institution. A good immediate result was defined as valve area ≥ 1.5 cm 2 without mitral regurgitation > 2/4. BMC procedure was performed using the double balloon or the Inoue balloon techniques. Ore to predict late outcome of BMC in patients with mitral stenosis. Mean age of our population was 35.6 ± 12 years. A successful procedure was observed in 92.4% of cases. At a mean follow-up of 20 years, the rate of survival with freedom from mitral surgery, or repeat percutaneous mitral commissurotomy and with New York Heart Association class I or II was of 47.6 ± 2.4%. By multivariate analysis using Cox regression model, three predictors of poor late functional results were identified: prior commissurotomy ( P = 0.014), Wilkins score > 8 ( P < 0.0001) and final mitral valve area < 1.8 cm 2 ( P < 0.0001). From the results of this analysis, we sought to develop a scoring system using the items indicated in the table below. Patients were considered at low risk if the score was of 0 to 5 (17.6% of patients). They were considered at middle risk if the score was of 6 to 8 (37.8% of patients) and were considered at high risk if the score was of 9 to 14 (51% of patients) ( Table 1 ). Twenty-year outcome of balloon mitral commissurotomy in a relatively young population is very encouraging and can be predicted by a simple score.

Prognostic value of left ventricular strain imaging and brain natriuretic peptide after percutaneous mitral balloon commissurotomy

This study aimed (1) to evaluate the impact of pre-procedural two-dimensional speckle-tracking echocardiography (2D-STE) on long-term outcome after successful percutaneous mitral balloon commissurotomy (PMC) in patients with mitral stenosis (MS) and the prognostic value on BNP for restenosis. One hundred and twenty-two consecutive MS patients with preserved left ventricular ejection fraction (LVEF ≥ 50%) and who underwent successfully PMC were studied. Successful immediate result was defined as post-procedural mitral valve area ≥ 1.5 cm 2 and ≤ 2/4 mitral regurgitation by catheterization. During a follow-up of 5.5 ± 2.3.0 years, there were 14 hospitalisations for heart failure (11%) and 22 late mitralvalve reintervention for restenosis (18%) and 21 patients experienced atrial fibrillation (17%). Univariate predictors of heart failure were global longitudinal strain (GLS), age, right ventricular function, left atrial volume, BNP, and pre- and post-procedural pulmonary artery pressures (PAP). In the multivariate Cox model, GLS and PAP were the strongest predictor of HF [hazard ratio (HR) (95% CI), 1.56 (1.03–4.2); P = 0.01 and 1.26 (1.1–12.4); P = 0.02]. For atrial fibrillation and restenosis, LA volume, GLS and post-procedural left atrial pressure (LAP) were univariate predictors’ factors. Multivariable analysis, demonstrated that GLS and LA volume remained in the final model with interesting predictive value [GLS HR (95% CI), 1.27 (0.87–11.72); P = 0.056, 2.66 (1.24–12.44); P = 0.01]. There was no correlation between BNP value and restenosis. GLS and PAP are interesting predictor of long-term outcome after successful PMC and provides incremental prognostic value over traditional parameters. BNP and LA volume provide more informations regarding supraventricular arythmia on the follow-up.

Percutaneous mitral commissurotomy in patients over 50 years old: Immediate and long-term results

Describe the immediate and final outcome of percutaneous mitral balloon commissurotomy (PMC) with Inoue balloon in patients over 50 years old and associate complications with age and Wilkins score. A retrospective and analytic study was performed with a database of 280 patients. We included all the patients proceeding in our department from January 1998 to December 2012. Seventy-five were > or = 50-years old (group 1). Immediate and late outcomes in this group (group 1) were compared with those in the patients aged < 50-years (group 2). Baseline hemodynamic parameters were comparable in the two groups. The Wilkins score was > 8 in 11 patients We found a Mitral Valvular Area (MVA) before the PMC proceeding of 0.99 cm 2 ± 0.2 and 1.87 cm 2 ± 0.38 post-PMC ( P < 0.001), with pre-procedure transmitral gradient of 12.7 ± 4.05 mmHg and of 4.4 ± 2.3 mmHg post-procedure ( P < 0.001). Similar significant improvements were seen in group 2. In 72 patients (96%) the immediate proceeding was considered successful. The hemodynamic result was good in 85.3% of group 1 patients. Tamponade occurred in one patient. Mitral regurgitation grade I or II developed in 8 patients and remained stable in 19 patients. These complication rates were comparable to those seen in group 2. A clinical and echocardiographic follow-up was performed in 68 patients (93%). In the group 1, a good result was maintained in 60% of patients after 75.8 ± 40 months of follow-up. Although restenosis was observed in 28% of patients, functional amelioration was obtained in most of cases. Survival free of mitral valve intervention or heart failure ≥ NYHA III was significantly better for patients with good immediate result. PMC is safe and efficacious in elderly patients with symptomatic mitral stenosis. Long-term results are good and related mainly to the quality of the procedure.

P480A simple score to predict late outcome of balloon mitral commissurotomy

P480A simple score to predict late outcome of balloon mitral commissurotomy

Net atrioventricular compliance can predict persistent pulmonary artery hypertension after percutaneous mitral balloon commissurotomy

BackgroundPulmonary hypertension is a common complication of rheumatic mitral stenosis (MS). Patients with similar mitral valve (MV) areas may have different pulmonary artery pressures. Net atrioventricular compliance (Cn) was found to play an important role in the development of pulmonary hypertension. AimTo test the value of Cn in predicting persistent pulmonary artery hypertension (PPAH) after percutaneous mitral balloon commissurotomy (PMBC). Patients and MethodsEighty patients with severe MS, suitable for PMBC were included in the study. We excluded patients with contraindication to PMBC, atrial fibrillation, failure of PMBC, and restenosis. All patients had undergone electrocardiography, echocardiography with measurement of MV area, systolic pulmonary artery pressure (SPAP), and Cn, PMBC, and follow-up echocardiography. ResultsPatients were divided into two groups: Group I: Cn<4.2mL/mmHg (36 patients), Group II: Cn≥4.2mL/mmHg (44 patients). Group I patients had significantly higher SPAP, and significantly lower SPAP reduction. Sensitivity of Cn<4.2mL/mmHg in prediction of PPAH was 88.9%, specificity was 88.6%, and accuracy was 88.8%. Independent predictors for PPAH were baseline Cn (p=0.0027), and Cn improvement after PMBC (p=0.0085). There was a significant negative correlation between Cn and baseline SPAP (r=−0.349, p=0.0015), and a significant positive correlation between Cn and percent SPAP reduction (r=0.617, p<0.00001). ConclusionMeasuring Cn can predict PPAH in MS patients after PMBC. It also may add value in evaluating MS patients undergoing PMBC and may help in predicting their prognosis.

Transesophageal Echocardiographic Guidance for Septal Puncture and Balloon Mitral Commissurotomy

Interatrial septal puncture has become more and more important in the era of percutaneous intervention for structural heart diseases. Some arrhythmia ablation procedures may also require septal puncture. However, septal puncture is probably one of the most risky percutaneous intervention techniques. It may inadvertently perforate the atrial wall or the ascending aorta, leading to cardiac tamponade or even death. Online guidance with TEE can dramatically reduce the risk. Selection of optimal bicaval plane is of paramount importance. The Brockenbrough puncture needle within the Mullin sheath should be managed so that the typical tenting sign can appear on this plane before protruding the puncture needle. Online TEE is also very convenient for guiding balloon commissurotomy in patients with mitral stenosis. It can provide immediate post-dilatation hemodynamic information through Doppler measurements, and reveal flail mitral valve if the chordae have ruptured. It can reduce the risk of cerebral embolism in patients with isolated immobile appendageal thrombus, if they decide to undergo balloon commissurotomy after anticoagulation for more than three months. Importantly it can detect life-threatening complications such as pericardial tamponade promptly and reliably. Indeed, mastering the technique of online TEE guidance is truly rewarding for balloon mitral commissurotomy.

Tips and Tricks of Transesophageal Echocardiographic Guidance During Cardiac Interventions

Online transesophageal echocardiographic (TEE) guidance has become a useful and convenient technique for various structural heart disease interventions, e.g., interatrial septal puncture, balloon mitral commissurotomy, mitraClipping, atrial septal defect (ASD) device closure etc. There are some important tips and tricks. (1). For septal puncture, 2D echo may be better than 3-D echo. The optimal tenting sign should be managed to appear on the bicaval plane before protruding the puncture needle. If the tenting sign appears on a plane showing the right upper pulmonary vein, it indicates that the needle is pointing too posteriorly, increasing the risk of atrial wall perforation. Conversely, if the tenting sign appears on a plane showing the ascending aorta, it indicates that the needle is pointing too anteriorly, increasing the risk of aortic perforation. (2). Live 3D zoom mode is very convenient and better than 2D for monitoring ASD device deployment. (3). Fluoroscopy is still useful for monitoring some parts of the intervention procedures. If available, fusion imaging would be very convenient. (4). The duration of using color Doppler and 3-D echo should be kept short. Long duration tends to elevate the temperature of the TEE probe. (5). When using loop function, the time mode may be more desirable than the beat mode to prevent interruption of an important recording.

682 - Predictors of successful percutaneous mitral balloon commissurotomy in patients with severe mitral stenosis

682 - Predictors of successful percutaneous mitral balloon commissurotomy in patients with severe mitral stenosis

Pulmonary hypertension in rheumatic mitral stenosis revisited.

In patients with mitral stenosis (MS), pulmonary hypertension (PH) is asignificant contributor to the associated morbidity. We aimed to study factors associated with the presence of significant PH (sPH) and whether incorporating body surface area (BSA) in the mitral valve area (MVA) would improve the predictive value of the latter. The medical records of 558 patients with severe MS undergoing percutaneous balloon mitral commissurotomy were evaluated over aperiod of 8years. Factors associated with the presence of significant PH (sPH) defined as mPAP≥ 40 mmHg were examined. Atotal of 558 patients (423 women) were enrolled. Overall, 153 (27%) patients had sPH. Patients with sPH were similar to the rest of the subjects in terms of demographics, body habitus, blood group, and incidence of atrial fibrillation. Among echocardiographic findings, absolute MVA, indexed MVA, and mean transmitral valve gradient were associated with the presence of sPH. Transmitral valve gradient during right heart catheterization had the highest area under the curve for an association with sPH. Age, gender, heart rhythm, and blood group were not associated with the presence of sPH in severe MS. The predictive value of the indexed MVA for the presence of sPH was not higher than that of absolute MVA.