Percutaneous Balloon Mitral Valvuloplasty Research Articles

Relationship between Wilkins echocardiographic score and neutrophil to lymphocyte ratio in patients with rheumatic mitral stenosis

OBJECTIVE: Wilkins echocardiography score (WS) is commonly used for patients with rheumatic mitral stenosis (RMS) to evaluate their eligibility for percutaneous mitral balloon valvuloplasty (PMBV) treatment. Patients with WS of higher than 11 are not eligible for PMBV treatment. Previous studies demonstrated that inflammation might play a role in RMS progression. The purpose of this study was to investigate the role of neutrophil/lymphocyte ratio (N/L ratio), which is an indicator of inflammation in predicting high WS. MATERIALS and METHODS: In this retrospective study, we investigated 115 patients (93 females, 22 males) with moderate to severe RMS. Transthoracic and transesophageal echocardiography reports were analysed. Patients were divided into two groups according to their Wilkins scores. Patients with a WS ≤ 11 were included in Group 1 and those with a WS >11 were included in Group 2. The echocardiographic and haematological parameters of the groups were compared. RESULTS: Group 1 consisted of 72 patients (mean age 43.7±12.0) and group 2 consisted of 43 patients (mean age 52.7±11.3). In Group 1, the mean WS was 7.4±2.0 while it was 12.4±0.7 in Group 2. The N/L ratio was 3.8±0.5 in Group 2 and it was significantly higher than that of Group 1, which was 2.6±0.9 (p 11 in patients with RMS.

Mitral balloon valvuloplasty followed by closure of the left atrial appendix in presence of thrombi and recurrent stroke

Hemodynamic consequences of mitral stenosis as well as inflammatory and structural changes in the left atrium increase the risk of developing atrial fibrillation and predispose to thrombus formation, primarily in the left atrial appendage. Percutaneous mitral balloon valvuloplasty for hemodynamically severe rheumatic mitral stenosis with favorable valve anatomy reduces the risk of thromboembolic events and stroke. Although the presence of left atrial thrombus is determined as a contraindication, percutaneous intervention has been found to be safe when the thrombus is localized to the atrial appendix. Left atrial appendix occlusion is an alternative treatment of choice for stroke prevention in patients with high stroke risk in whom oral anticoagulation is contraindicated or in patients with thromboembolic events in spite of adequate anticoagulation. Here we report a case of a 91-year-old-woman with very severe mitral stenosis and chronic atrial fibrillation, with a left atrial appendix thrombus and a history of recurrent stroke despite warfarin. Balloon valvuloplasty was performed firstly without encountering any embolic events. The thrombus was dissolved following restored of the left atrial flow. Subsequently, atrial appendix occlusion device was implanted in order to reduce the risk of recurrent thromboembolic events.

Platelet distribution width can be a useful marker of decreased platelet activity after percutaneous mitral balloon valvuloplasty

Aim: Increased platelet activity and elevated mean platelet volume (MPV) has been demonstrated in patients with rheumatic mitral stenosis (RMS). However, platelet distribution width (PDW) and the impact of percutaneous mitral balloon valvuloplasty (PMBV) on PDW has never been studied. Therefore, we aimed to investigate whether PMBV decreases PDW in patients with RMS.Material and Methods: Symptomatic patients with severe RMS undergoing PMBV were included. Echocardiographic characteristics and hematologic parameters was measured just before and 1 month after the PMBV procedure.Results: A total of 30 patients (24 female, mean age: 49.8±13.2 years) were included the study. Mean transmitral pressure gradient, pulmonary artery pressures and left atrium diameter decreased but mitral valve area increased significantly after PMBV. PMBV procedure significantly decreased PDW in patients with RMS (13.5±2.3 vs 12.4±1.9 fL, before and after procedure, respectively; p<0.0001). MPV was decreased after PMBV but it was not statistically significant (10.9±0.8 vs 10.6±0.9 fL, p=0.056). Platelet count was significantly increased after procedure (250±62.6 vs 273.5±78.6 x103/ul, p=0.035). In linear regression analysis, an independent relationship was found in magnitude of PDW decrease and magnitude of increase in mitral valve area (ẞ:0.491, p=0.046). Conclusion: PMBV is associated with a significant decrease in PDW 1 month after the procedure. There was a significant correlation between the magnitude of decrease in PDW and magnitude of increase in mitral valve area after PMBV.

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.

Study on the long-term curative effect of repeat percutaneous balloon mitral valvuloplasty in patients with mitral restenosis.

To study the long-term curative effect of repeat percutaneous balloon mitral valvuloplasty (PBMV) in patients with mitral restenosis.In our study, mitral restenosis developed in 39 patients after PBMV. Repeat PBMV was performed according to the improved Inoue method. All patients were followed up.Of 39 patients, 36 were successfully treated with repeat PBMV (achievement ratio, 92.3%). Immediately after repeat PBMV, clinical symptoms and left atrial mean pressure (LAP), pulmonary artery systolic pressure (PASP), mitral valve gradient (MVG), and mitral valve orifice area (MVA) improved significantly (24.50 ± 6.54 mmHg vs 9.66 ± 4.21 mmHg for LAP, 1.05 ± 0.19 cm2 vs 2.23 ± 0.22 cm2 for MVA, 17.03 ± 4.52 mmHg vs 7.79 ± 4.07 mmHg for MVG, 58.12 ± 12.68 mmHg vs 31.45 ± 10.02 mmHg for PASP; P <.05). Meanwhile, left atrial end-diastolic dimension (LAD) was altered slightly (4.71 ± 0.75 vs 4.07 ± 0.69, P >.05). The 36 patients were followed up for 69 ± 23 (12–146) months. After long-term follow-up immediately after repeat PBMV, the results did not show a significant change (2.23 ± −0.22 cm2 vs 2.02 ± −0.21 cm2 for MVA, 7.79 ± −4.07 mmHg vs 9.15 ± -4.11 mmHg for MVG; P >.05) and were approximated to those shortly after repeat PBMV (2.23 ± 0.22 cm2 vs 2.02 ± 0.21 cm2 for MVA, 7.79 ± 4.07 mmHg vs 9.15 ± 4.11 mmHg for MVG; P > 0.05). LAD did not change significantly (4.13 ± 0.71 cm vs. 4.07 ± 0.69 cm; P >.05). The long-term follow-up results showed that cardiac function and quality of life were significantly improved in most patients.It would be safe for patients with mitral restenosis to undergo repeat PBMV. Appropriate cases should be selected, and treatment should be performed cautiously. Short- and long-term curative effects would be satisfactory. We suggested that repeat PBMV be the first choice for patients with mitral restenosis after first PBMV.

Survival analysis of patients with rheumatic MS after PBMV compared with MVS in alow-to-middle-income country.

IntroductionRheumatic mitral stenosis continues to be prevalent in developing countries, notably in endemic areas. Over the last few decades, percutaneous balloon mitral valvuloplasty (PBMV) has been established as a lower-cost alternative treatment for mitral stenosis (MS) in low-to-middle-income countries. PBMV has also been suggested to be an effective and safe alternative treatment modality. This study aims to analyse the survival of rheumatic MS patients treated with PBMV compared with those treated with mitral valve surgery (MVS).MethodsThis study was a national, single-centre, longitudinal study using a survival analysis method in 329 consecutive patients suffering from rheumatic heart disease with severe MS who underwent PBMV compared with 142 consecutive patients with similar characteristics who underwent MVS between January 2011 and December 2016. Survival analysis and event-free duration were determined over a median follow-up of 24 months in the PBMV group and 27 months in the MVS group.ResultsThe results showed that of the 329 consecutive patients in the PBMV group, 61 patients (18.5) had an event (6 patients died and 55 patients were hospitalised), and of the 142 consecutive patients in the MVS group, 19 patients (13.4%) had an event (5 patients died, and 14 patients were hospitalised). The hazard ratio was 0.631 (95% confidence interval, 0.376–1.058; P = 0.081). Longer short-term survival was found in the MVS group but was not statistically significant. Event-free survival was significantly longer in the MVS group (P = 0.002), by 5 months.ConclusionsIn this study, the efficacy and safety of PBMV was reconfirmed, as PBMV proved to be non-inferior to MVS in survival prognosis, but sustained event-free duration was significantly better in the MVS group than in the PBMV group.

Influence of mitral valve morphology on short-term and long-term outcomes in elderly patients undergoing percutaneous balloon mitral valvuloplasty

Objective To explore the effect of mitral valve morphology on short-term and long-term outcomes in elderly patients with rheumatic mitral stenosis(MS)undergoing percutaneous balloon mitral valvuloplasty(PBMV). Methods In the prospective study, elderly patients with rheumatic mitral stenosis undergoing PBMV between February 1996 and June 2007 were followed up for 10 years.One hundred and twenty-four patients with full follow-up data were included in the study.According to echocardiography Wilkins score, 83 cases of patients(Wilkins score ≤8)were selected as Wilkins score ≤8 group, and 41 cases were selected as Wilkins score>8 group.The pressure gradient in mitral valve(MV△P), mitral valve area(MVA), left atrial diameter(LAD), left ventricular end-systolic diameter(LVESd), left ventricular end-diastolic diameter(LVEDd), pulmonary artery systolic blood pressure(sPAP), ejection fraction(EF)and mitral regurgitation were measured before and after the operation. Results In both Wilkins score ≤8 group and Wilkins score>8 groups, MVA and EF were increased immediately after PBMV operation versus before PBMV operation, and MV△P, LAD, LVEDd, LVEDs and PAPs were decreased immediately after PBMV operation versus before PBMV operation(all P 0.05). MVA and EF in the Wilkins score>8 group were decreased, and MV△P, LAD, LVEDd, LVEDs and PAPS were increased after 10 years as compared with those immediately after PBMV(P 8 group(26.5% or 22/83 vs.46.3% or 19/41, χ2=4.879, P=0.027). And the incidence of mitral restenosis was lower in the ≤8 group than in the Wilkins score>8 group(34.9% or 29/83 vs.61.0% or 25/41, χ2=7.567, P=0.006). There was no significant difference in the incidence of moderate or severe mitral regurgitation between the two groups(10.8% or 9/83 vs.12.3% or 5/41, χ2=1.278, P=0.258). Conclusions The short-term and long-term outcomes are good in elderly individuals with rheumatic mitral stenosis undergoing PBMV operation, and the curative effect of PBMV operation is better in patients with Wilkins score ≤8 than in patients with Wilkins score >8. Key words: Mitral valve; Balloon dilatation

Long-Term Follow-Up of Atrial Septal Defect Closure after Percutaneous Balloon Mitral Valvuloplasty by Transesphageal Echocardiography?

Percutaneous Balloon Mitral Valvuloplasty (PBMV) involves atrial septostomy during the procedure. One of the consequences of transseptal puncture is the creation of an Atrial Septal Defect (ASD). Transesophageal Echocardiography (TEE) can detect Left to Right (L-R) shunts too small to be detected by other methods. The aim of this study was to evaluate the 3 years follow-up of ASD closure after PBMV by TEE. 200 consecutive patients with rheumatic Mitral Stenosis (MS) who underwent successful PBMV by using the Inoue balloon catheter were studied prospectively. ASD with small L-R atrial shunting occurred in all the patients (100%) immediately after PBMV. Total study 200 patients. All the ASDs were small in size (≤ 5 mm). The puncture site (ASD site) occurred in the fossa ovalis (Fo.Ov) in 120 patients (60%), while it occurred outside the Fo.Ov (either in the superior limbus or in the inferior limbus of the Interatrial Septum (IAS)) in the other 80 patients (40%). 180 patients presented at 6 month follow-up. ASD was closed in 117 patients (65%), while it was persisted in 63 patients (35%). 95 patients presented at 3 years follow-up. ASD was closed in 76 patients (80%) (Group I), while it was persisted in 19 patients (20%) (Group II). All the 74 patients who had ASD immediately after PBMV in the Fo.Ov, presented with ASD closure at 3 years follow-up. Only 2 patients who had ASD immediately after PBMV outside the Fo.Ov, presented with ASD closure at 3 years follow-up. All the 19 patients who presented at 3 years follow-up with ASD persistence had ASD immediately after PBMV outside the Fo.Ov (14 in the superior limbus and 5 in the inferior limbus). No patient presented at 3 years follow-up with ASD persistence, had ASD immediately after PBMV in the Fo.Ov Large LAD, high total Echocardiographic (echo) score of the Mitral Valve (MV), thick Fo.Ov, thick superior limbus, thick inferior limbus and ASD site immediately after PBMV outside the Fo.Ov were significant predictors of ASD persistence at 3 years follow-up. In conclusion, ASD with L-R atrial shunting occurs in all the patients after PBMV by using the Inoue balloon catheter. ASD after PBMV persists in 20% of the patients at 3 years follow-up. Predictors of ASD persistence at 3 years follow-up are: large LAD, high total echo score of the MV, thick Fo.Ov, thick superior limbus, thick inferior limbus and ASD site immediately after PBMV outside the Fo.Ov. ASD closes at 3 years follow-up in all the patients who had ASD in the Fo.Ov immediately after PBMV. All the patients with ASD persistence at 3 years follow-up had ASD outside the Fo.Ov after PBMV. It is recommended that operators doing transseptal puncture during PBMV by using the Inoue balloon catheter should aim to do it in the Fo.Ov.

Immediate And Long Term Effects Of Percutaneous Mitral Balloon Valvuloplasty On Atrial Conduction Velocities In Patients With Mitral Stenosis.

P-wave dispersion (PWD) is an electrocardiographic (ECG) marker of nonuniform and heterogeneous atrial conduction with ECG leads of different orientation. The aim of our study was to investigate the immediate and long term effects of successful percutaneous mitral balloon valvuloplasty (PMBV) on PWD in severe rheumatic MS patients and to analyse the restenosis, atrial fibrillation (AF) and redo balloon valvuloplasty rate. We enrolled 41 consecutive MS patients with sinus rhythm who underwent PMBV. A 12-lead ECG and transthoracic echocardiography were performed for each patient one day before, within 72 hours after the procedure and followed up by clinical visit at a mean of 5,57±1,46 (3-8) year.The mean patient age was 44.1±10.86 years. Pmax 1(pre PMBV) and PWD 1(pre PMBV) decreased 1-3 days after PMBV. MVA improved immediately after the procedure; but lately the mean MVA decreased significantly indicating the initiation of restenosis. Composite endpoints were associated with LA 1 (p = 0.02), MVA 2 (1-3 days after PMBV) (p= 0.019), mean gradient 2 (p= 0.028), PWD 3 (3 years after PMBV) (p < 0.001) and Pmax 3 (3 years after PMBV) (<0,001). AF incidence was associated with PWD 2 (p=0,019) and PWD 3 (p=0,010). There was 14 composite endpoint on follow up and at multivariate analysis PWD 3 was identified as an independent predictor of the composite endpoint (p=0.048, hazard ratio=1.36, 95% confidence interval (CI): 1,002-1.867). This study has demonstrated that Pmax and PWD significantly decreased within 3 days after PMBV. Furthermore, long term PWD was associated with AF and identified as an independent predictor of the composite endpoint.

Left Ventricular Torsion before and after Percutaneous Mitral Balloon Valvuloplasty

Background: The valve disease is frequently caused by the rheumatic mitral stenosis in developing and developed countries alike and it is still a key issue. Although there is a significant decrease in rheumatic fever diffusion, its percentage is still about 12% of the native valvular heart disease. Aim of Work: The key objective of this work was to assess the impact of percutaneous mitral balloon valvuloplasty (PMBV) on the LV torsion and this objective was achieved by using the two-dimensional speckle-tracking echocardiography. Patients and Methods: The study used the prospective observational method and had been carried out in the Department of Cardiology, Al-Azhar University Hospitals. The treatment group consisted of 35 patients who were candidates for PMBV and the control group consisted of 20 matching patients in terms of gender and age but they were healthy. All the participants of study had been assessed using the conventional echocardiography and speckletracking echocardiography on the previous day and 3 months after the procedure. Results: Using the parameters of the conventional echocardiography, we found that there were no significant differences between the treatment group and the control group in the LV ejection fraction (EF) and RV systolic function (TAPSE) before the PMBV. After applying the Speckle-tracking echocardiography, the results indicated that LV torsion decreased in the treatment group compared to the control group before the PMBV. After 24 hours and 3 months after the PMBV, the patients of treatment group had shown a statistically significant improvement in LV torsion. Conclusion: The LV torsion in MS patients significantly improved immediately and in the short-run follow-up after the PMBV

Left Ventricular Torsion before and after Percutaneous Mitral Balloon Valvuloplasty

Background: The valve disease is frequently caused by the rheumatic mitral stenosis in developing and developed countries alike and it is still a key issue. Although there is a significant decrease in rheumatic fever diffusion, its percentage is still about 12% of the native valvular heart disease. Aim of Work: The key objective of this work was to assess the impact of percutaneous mitral balloon valvuloplasty (PMBV) on the LV torsion and this objective was achieved by using the two-dimensional speckle-tracking echocardiography. Patients and Methods: The study used the prospective observational method and had been carried out in the Department of Cardiology, Al-Azhar University Hospitals. The treatment group consisted of 35 patients who were candidates for PMBV and the control group consisted of 20 matching patients in terms of gender and age but they were healthy. All the participants of study had been assessed using the conventional echocardiography and speckletracking echocardiography on the previous day and 3 months after the procedure. Results: Using the parameters of the conventional echocardiography, we found that there were no significant differences between the treatment group and the control group in the LV ejection fraction (EF) and RV systolic function (TAPSE) before the PMBV. After applying the Speckle-tracking echocardiography, the results indicated that LV torsion decreased in the treatment group compared to the control group before the PMBV. After 24 hours and 3 months after the PMBV, the patients of treatment group had shown a statistically significant improvement in LV torsion. Conclusion: The LV torsion in MS patients significantly improved immediately and in the short-run follow-up after the PMBV

Transesophageal echocardiography and scopy co-guided percutaneous mitral balloon valvuloplasty procedure: Experience of a tertiary health center with a literature review

Objective: Rheumatic valvular heart disease (RVHD) is an important health problem in Turkey, as in all developing countries. There is no exact prevalence data for RVHD in Turkey. But according to the Jones criteria, Turkey has a moderate risk for acute rheumatic fever (ARF). Patients with recurrent bouts of ARF resulting in carditis can progress to RVHD. The aim of this study was to evaluate percutaneous mitral balloon valvuloplasty (PMBV) procedures and compared the findings with the literature. Materials and Methods: PMBV procedure indication was determined according to the guidelines and heart team consensus. Echocardiography was evaluated prior to PBMV in all patients. The study included a total of 131 patients who underwent PMBV in the cardiology clinic of our hospital in the period 2007–2017. All PBMV procedures were performed under intraprocedural transesophageal echocardiography (TEE) guidance in addition to fluoroscopy with general anesthesia. Results: The patients comprised 83% female and 17% male with a mean age of 41.2 ± 10.1 years. Mean ejection fraction was 60.3% ± 3.1%, mean left atrium diameter was 46.7 ± 5.3 mm, and mean Wilkins score was 8.7 ± 1. After procedure with there was no mortality. There was statistically significant increase on mitral valve area and statistically significant decrease on pulmonary arterial pressure and statistically significant decrease on transmitral gradient. Conclusion: This is one of the few studies worldwide to have detected the safety and efficacy of PBMV with TEE and scopy coguidance. It is the first such study in Turkey. In accordance with the literature, the procedures performed with TEE and fluoroscopy co-guidance in our clinic have increased the safety of the procedure and decreased complication rates.

Surgical & Interventional Management of Rheumatic Valvular Heart Disease at The Prince Charles Hospital from January 2005–December 2017

Background: The incidence of rheumatic heart disease (RHD) in the indigenous Australian population is the highest in the world. 240 indigenous patients underwent any valve related surgical and interventional procedures at Metro North HHS from January 2005-December 2017. Of these 75 were performed for rheumatic valves at TPCH. Methods: Chart review and electronic database procedural data was analysed, with clinical follow up records, including echocardiography, being collated to identify survival and cardiac status following these interventions. Results: Rheumatic interventions were required over an age range of 10–72 years dominantly female 82%. Percutaneous mitral balloon valvuloplasty was performed in 15 patients, transcatheter aortic valve implantation in 1 patient. Surgical valve repair of 11 isolated mitral valves was achieved. Single valve replacement was done in 10 with multiple valve repair/replacements required in the remaining 38 patients. Mechanical and tissue valves were used almost equally during replacement. Valve failure due to mitral valve thrombus formation, aortic prosthetic patient mismatch, and endocarditis required 8 reoperations. One reoperation following mitral valve repair has been required to date. Pre and post procedure LVEF mean of 56% (range 33–80%) and 57% (range 28–75%) respectively. 30-days hospital survival was 100%, 5 year was 88% and 12 year was 84%. Valve function on follow up with clinical and echo data remains satisfactory. Conclusions: Mitral valve function is durable following valvuloplasty or surgical repair in RHD. Risk to survival during all forms of intervention is low. The type of systemic heart valve utilised for replacement requires close consideration of patient geography, medical access and patient compliance.

Interventional Management of Indigenous Rheumatic Valvular Heart Disease at TPCH

Background: The incidence of rheumatic heart disease (RHD) in the indigenous Australian population is the highest in the world. Review of Queensland Patient Admitted Data Collection and TPCH cardiac clinical databases between January 2005 to December 2017 identified 240 indigenous patients undergoing any valve related interventional procedures at Metro North HHS. Of these 75 were performed for rheumatic valves at TPCH. Methods: Chart review and electronic database procedural data was analysed, with clinical follow up records, including echocardiography, being collated to identify survival and cardiac status following these interventions. Results: Rheumatic interventions were required over an age range of 10–69 years dominantly female 75%. Percutaneous mitral balloon valvuloplasty was performed in 15 patients, transcatheter aortic valve implantation in 1 patient. Surgical valve repair of 11 isolated mitral valves was achieved. Single valve replacement was possible in 10 with multiple valve repair/replacements required in the remaining 38 patients. Mechanical and tissue valves were utilized by 12 surgeons almost equally during replacement. Valve failure due to mitral valve thrombus formation, aortic prosthetic patient mismatch, and endocarditis required 7 reoperations. Hospital 30-day survival was 100%, 5year survival was 90% and 12year survival was 85%, estimated from medical record review. One reoperation following mitral valve repair has been required to date. Valve function on late follow up with clinical and echo data remains satisfactory. Conclusions: Mitral valve function is durable following balloon valvuloplasty or surgical repair in RHD. Risk to survival during all forms of intervention is low. The type of systemic heart valve utilized for replacement requires close consideration of patient geography, medical access and patient compliance.

Three-Dimensional Echo and Three-Dimensional Transesophageal Echocardiography for Mitral Valve Disease

Three-dimensional (3D) echocardiography is one of the greatest technologies, which has a significant contribution in the field of valvular heart disease, especially after the development of real-time (RT) capability in transthoracic as well as transesophageal imaging during the past decade. RT 3D transesophageal echo has provided a simplified imaging tool for the anatomy of mitral valve (MV), including the MV annulus, leaflets, and subvalvular apparatus. Three scallops of anterior and posterior leaflets are easily recognized. This helps in localizing the MV abnormality, for example, MV prolapse and flail MV. This also helps in localizing the mitral regurgitation (MR). Even the quantification of MR has also seen a novel understanding of RT 3D planimetry of MR jet, which is possible by newer machines. Commissural inequality and calcification is well identified, and it helps in choosing the cases for percutaneous balloon mitral valvuloplasty. More recently, this technology with RT 3D transesophageal echocardiography has found a role in interventional procedure, for example, balloon mitral valvuloplasty, paravalvular leak closure, and edge-to-edge (MitraClip) repair of degenerative MV.

Combined cesarean section and mitral valve replacement in severe symptomatic mitral valve disease with unfavorable valve anatomy: Experience at a tertiary referral center of North India

Objective: To discuss the management in a subset of patients with severe mitral valve disease having calcified, nonpliable valves not suitable for percutaneous balloon mitral valvuloplasty during pregnancy, presenting with Stage III–IV of the clinical classification of New York Heart Association. Methods: Patients with nonpliable valves presenting with heart failure in pregnancy at advanced gestation were planned for simultaneous cesarean section followed by mitral valve replacement. Results: All patients underwent successful surgery with good maternal and neonatal outcome. Conclusion: Patients with severe mitral valvular disease in failure in pregnancy, who are at high risk of mortality in pregnancy or during and following delivery, benefit from combined surgery.

Right ventricular dyssynchrony and functional capacity before and after percutaneous balloon mitral valvuloplasty in patients with mitral stenosis: Determinants and clinical impact.

We aimed to investigate the utility of right ventricular (RV) dyssynchrony to assess functional capacity utilizing 6-minute walking test distance (6MWTD) and to measure brain natriuretic peptide levels (BNP) in patients with mitral stenosis (MS) and to study its value to predict adverse outcome following percutaneous balloon mitral valvuloplasty (PBMV). A total of 108 patients with moderate to severe MS (26.5±7.5years) were included in this study. All were candidates for PBMV. RV strain curves were obtained using two-dimensional speckle-tracking echocardiography, and standard deviation (SD) of 4 segments without RV apex (-SD4) was also assessed. 6MWT and BNP were before and after 12months following PBMV. RV-SD4 was significantly prolonged in patients with MS compared with controls (P<0.001). Patients with 6MWTD ≤300m had a significantly increased RV-SD4 (P<0.001) and had higher BNP values (P<0.03) compared with those with 6MWTD >300m. RV-SD4 showed a strong correlation with 6MWT and BNP level. RV-SD4 was the strongest independent predictor of adverse outcome following PBMV (P<0.0001). Receiver operating characteristic analysis showed that RV-SD4 ≥24ms was the cutoff value which predicts the adverse outcome following PBMV. A considerable improvement of mean 6MWT with significant reduction of BNP levels after 12months of follow-up (P<0.001) in subjects with RV dyssynchrony <24ms. Right ventricular dyssynchrony is a useful predictor of functional status, as assessed with 6MWTD and BNP level in patients with MS. Furthermore, it might be considered as an independent predictor of adverse outcome following PMBV.

Measurement of interatrial septal thickness by echocardiography in patients with moderate to severe rheumatic mitral stenosis undergoing percutaneous balloon mitral valvuloplasty

BackgroundLongstanding severe rheumatic mitral stenosis (MS) is associated with changes in the atrial chamber dimensions. It is not known whether there is an increased thickness of the inter-atrial septum (IAS) in patients with severe rheumatic mitral stenosis. The objective of this study was to evaluate pre-procedural IAS thickness by echocardiography in patients with moderate to severe rheumatic mitral stenosis undergoing percutaneous balloon mitral valvuloplasty (PBMV). MethodsThe thickness of the IAS was measured by transesophageal echocardiography (TEE) in 86 patients between 14 and 65 years of age. Patients with moderate to severe rheumatic mitral stenosis undergoing percutaneous mitral balloon valvuloplasty (PMBV) at the National Institute of Cardiovascular Diseases (NICVD), Karachi were recruited for this study. IAS thickness was measured by TEE using standard views and 3 different phases of cardiac cycles were evaluated. ResultsOut of 86 patients, almost three fourths (73.3%) were between 14 and 29 years of age and two thirds (62.8%) were females. Mean IAS thickness was 2.56 (SD 0.92) mm at anterior region (AR), 1.89 (SD 0.75) mm at fossa ovalis (FO), and 2.95 (SD 0.97) mm at posterior region (PR). None of the demographic and clinical groups showed any statistically significant difference in IAS thickness. ConclusionsInter-atrial septum (IAS) thickness measurement does not change in the presence of moderate to severe rheumatic mitral stenosis as compared to the reported normal values of IAS thickness in cadaveric hearts.

Immediate Results of Percutaneous Mitral Balloon Valvuloplasty in Patients with Mitral Stenosis

Introduction: Mitral stenosis is a prevalent valvular disease in developing countries. Percutaneous mitral balloon valvuloplasty (PMBV) is the gold standard treatment. The main objective of this study was to assess the initial results of PMBV in patients with mitral stenosis during 16 years (2002-2018) in Mashhad, Iran. Materials and Methods: From April 2002 to March 2018, 770 patients underwent PMV in department of cardiology. PMV was performed by the antegrade transseptal method using the Inoue balloon. Results: The obtained success rate was 97%. In this study, the valve area increased from 0.9±1.1 to 1.8±0.2 cm2 (P<0.0001). There was no case of peri-procedural death or cardiac tamponade. Additionally, 0.25% of the patients required mitral valve replacement. Severe mitral regurgitation occurred in 0.9% of the subjects. There was no case of cerebrovascular accident, transient ischemic attack, embolic myocardial infarction, or cardiac perforation. Supraventricular tachycardia occurred in 2.59% of the patients. Conclusion: The PMBV by the Inoue technique is a feasible and easy procedure with a short crossing times and low complications.

PO628 Inoue Balloon Versus Single Balt Balloon Technique In Percutaneous Mitral Balloon Valvuloplasty. Results, In-Hospital Evolution and Cost

In-stent restenosis (ISR) remains a problematic issue of coronary intervention. The non-slip element balloon (NSE) is a balloon catheter with 3 longitudinal nylon elements which are attached proximally and distally to the balloon component. The expectation is that this design of balloon is able to achieve a larger lumen area due to the elements, as well as reducing balloon slippage. We investigated whether NSE pre-dilatation improves angiographic outcomes compared to a high pressure non-compliant balloon pre-dilatation, followed by a drug-coating balloon (DCB) for treatment of ISR lesions with optical coherence tomographic imaging (OCT).Patients were eligible for the study if one or more in-stent restenosis lesions were treated with a paclitaxel-coating balloon. Patients were randomized to NSE pre-dilatation (NSE group) or high pressure non-compliant balloon pre-dilatation (POBA group) in a 1:1 fashion in 17 hospitals. The primary endpoint was in-segment late loss [post minimal lumen diameter (MLD) − follow-up MLD] at 8 months.One hundred and five patients were allocated to each group. Balloon slippage (7.9% versus 22.9%, p = 0.002) and geographical miss (6.9% versus 21.9%, p = 0.002) were observed less in the NSE group compared to the POBA group. Acute gain was significantly larger in the NSE group (1.17 ± 0.42 mm versus 1.06 ± 0.35 mm, p = 0.04), but post minimum stent lumen area analyzed by OCT was similar between the two groups (3.85 ± 1.67 mm2 versus 3.81 ± 1.93 mm2, p = 0.64). At 8 months, average lesion length was significantly shorter than the POBA group (5.78 ± 3.26 mm versus 6.97 ± 4.59 mm, p = 0.04), but average in-segment late loss was similar between the two groups (0.28 ± 0.45 mm versus 0.27 ± 0.38 mm, p = 0.75).Eight-month angiographic outcomes were similar between NSE and non-compliant balloon pre-dilatation with DCB for treatment of ISR lesions. However, NSE pre-dilatation has advantages such as reduction of balloon slippage and geographical miss during the procedure.