Postprocedural Mitral Valve Area Research Articles

Accomplishments and Perspectives with Retrograde Nontransseptal Balloon Mitral Valvuloplasty

Retrograde nontransseptal balloon mitral valvuloplasty (RNBMV) is a transarterial technique of mitral valvuloplasty, developed with the aim to avoid complications associated with transseptal catheterization. Between April 1988 and December 1999, RNBMV has been attempted in 393 patients with symptomatic mitral stenosis (aged 44 ± 11 years, 322 women, mean echocardiographic score 7.7 ± 1.9) at the University of Athens, Greece. The procedure was completed in 392 cases. Technical success (gain in mitral valve area ≥ 50% with final mitral valve area ≥ 1.5 cm2, and absence of postprocedural mitral regurgitation grade > 2+) was achieved in 344 (87.5%) patients. Unfavorable predictors for immediate outcome included the echocardiographic score (P < 0.001). male gender (P = 0.005), and preprocedural mitral regurgitation (P = 0.003). Complications included death (0.3%), severe mitral regurgitation (3.1%), and femoral artery injury (0.8%). No cases of cardiac peqoration or tamponade have occurred with RNBMV. Patients with a successful immediate outcome were followed clinically for 4.8 ± 2.8 years (maximum 12 years). Event‐free (freedom from cardiac death, mitral valve replacement, redo valvuloplasty, and recurrence of NYHA Class > II) survival rates at 1, 2, 5, and 12 years post‐RNBMV were 99.7 ± 0.3%, 96.1 ± 1.1%, 84.7 ± 2.2%. and 67.6 ± 4.8%, respectively. The echocardiographic score (P < 0.001) and the postprocedural mitral valve area (P < 0.001) were significant independent predictors of long‐term outcome following RNBMV. Experience with RNBMV has fulfilled expectations regarding lowering of the risk of occurrence of specific cardiac complications encountered during mitral valvuloplasty, and reveals this approach as a safe and efficient alternative to the more commonly used antegrade technique.

Seguimiento actuarial tras valvulotomía mitral percutánea. Incidencia y factores predictores de eventos

The goal of this study is to analyse the follow-up of patients who underwent percutaneous mitral valvuloplasty and the predicting factors of event-free survival. We analysed 220 consecutive valvuloplasty performed between 1988 and 1996 in order to establish the incidence of events (death, restenosis, mitral valve surgery, New York Heart Association class IV, new valvuloplasty or systemic embolia) and the baseline and postprocedural characteristics predicting events, during a mean follow-up of 42 months (range 1-96 months). Overall survival was 94.7%, and event-free survival was 59.2% at 96 months. We analyzed the baseline characteristics in order to predict the mid-term outcome (actuarial survival Kaplan-Meier method) that atrial fibrillation (p < 0.01), age > or = 56 years (p < 0.005), and echocardiographic score > or = 9 (p < 0.005) were baseline characteristics related to adverse events in follow up. An index based on the number of adverse factors in the baseline characteristics provided a significant difference in concerning the number of follow up to even-free between the group without baseline adverse characteristics and the group with two (p = 0.008, OR = 4.5), or three adverse characteristics (p = 0.005, OR 6.4). Among the postprocedural characteristics, while patients with mitral valve area after valvuloplasty > or = 1.5 cm2 had an event-free survival of 72.9% at 96 months, those with postprocedural mitral valve area < 1.5 cm2 had an event-free survival of 10.5% (log-rank test p < 0.0001). Mid-term event-free survival after percutaneous mitral balloon valvuloplasty can be predicted by baseline and postprocedural characteristics. Age > or = 56, echocardiographic score > or = 9 and atrial fibrillation are baseline factors related with adverse events. Patients with 0 or 1 baseline adverse factors do not have significant differences concerning mid-term outcome while, those with 2, and above all, 3 adverse baseline characteristics have a poorer event-free survival. Mitral valve area > or = 1.5 cm2 is the only postprocedural independent predictor of event-free survival.

Long-term clinical and echocardiographic outcome in patients with mitral stenosis treated with percutaneous transvenous mitral commissurotomy.

Long-term follow-up after percutaneous transvenous mitral commissurotomy (PTMC) is limited. Ninety-four middle-aged (51+/-9 years) mitral stenosis patients who underwent successful PTMC were followed up with annual echocardiography for 6.1+/-1.4 years. PTMC success was defined as either mitral valve area (MVA) >1.5 cm2 or a MVA of more than twice the pre-procedural value, together with no worsening of mitral regurgitation >grade 2+. Mitral valve replacement (MVR), worsening of congestive heart failure (CHF), and thromboembolism were sought for survival analysis. Restenosis was defined as loss of more than 50% of the initial procedural MVA gain. Functional limit of daily activities was assessed through a questionnaire. The study population was divided into group 1 (post-procedural MVA >2.0 cm2), group 2 (MVA > 1.5 cm2 and < or = 2.0 cm2) and group 3 (MVA < or = 1.5 cm2). The 6-year survival with freedom from MVR, CHF, thromboembolism, and combined events (MVR+CHF) was 92%, 95%, 91%, and 88%, respectively. No group 1 patient experienced MVR or CHF. Restenosis was predominant in group 3. Deterioration of daily activities during follow-up was not observed in group 1; however, it was significant in group 2 (p<0.05) and group 3 (p<0.001). These results demonstrated that patients who attained a large MVA (>2.0cm2) immediately after PTMC maintained their procedural benefit with less clinical complication and with less limitation of daily activity.

Retrograde nontransseptal balloon mitral valvuloplasty: immediate results and intermediate long-term outcome in 441 cases—a multicenter experience

Objectives. Our aim was to present the immediate and intermediate long-term results of the application of retrograde nontransseptal balloon mitral valvuloplasty (RNBMV) in four cooperating centers from Greece and India.Background. RNBMV is a purely transarterial method of balloon valvuloplasty, developed with the aim to avoid complications associated with transseptal catheterization. Only single-center experience with RNBMV has been previously reported.Methods. The procedure was attempted in 441 patients with symptomatic mitral stenosis (320 women, 121 men, mean age [± SD] 44 ± 11 years, mean echocardiographic score [± SD] 7.7 ± 2.0) from 1988 to 1996. Three hundred eighty-five patients with successful immediate outcome were followed clinically for a mean [± SD] of 3.5 ± 1.9 (range, 0.5–9.1) years.Results. A technically successful procedure was achieved in 388 (88%) cases. The echocardiographic score (p < 0.001), male gender (p = 0.005), preprocedural mitral regurgitation (p = 0.007) and previous surgical commissurotomy (p = 0.029) were unfavorable predictors of immediate outcome. Complications included death (0.2%), severe mitral regurgitation (3.4%) and injury of the femoral artery (1.1%). Event-free (freedom from cardiac death, mitral valve surgery, repeat valvuloplasty and NYHA class > II symptoms) survival rates (± SEM) were 100%, 96.9 ± 0.9%, 89.8 ± 1.9% and 75.5 ± 5.5% at 1, 2, 4 and 9 years, respectively. The echocardiographic score (p < 0.001), NYHA class (p = 0.008) and postprocedural mitral valve area (p = 0.009) were significant independent predictors of intermediate long-term outcome.Conclusions. Multicenter experience indicates that RNBMV is a safe and effective technique for the treatment of symptomatic mitral stenosis. As with the transseptal approach, patients with favorable mitral valve anatomy derive the greatest immediate and intermediate long-term benefit from this procedure.

Predictors of long-term event-free survival after percutaneous balloon mitral valvuloplasty

Previous studies have shown that long-term event-free survival after percutaneous balloon mitral valvuloplasty (PBMV) could be predicted by several baseline characteristics. However, the extent of the predictive variables has not been defined accurately yet. In this study, 40 baseline demographic, clinical, echocardiographic, and hemodynamic variables of 128 consecutive patients with mitral stenosis who underwent PBMV in a single institution, were analyzed in order to predict long-term event-free survival, defined as absence of death, mitral valve replacement, or repeat PBMV. Univariate survival analysis showed that age (p = 0.03), history of commissurotomy or mitral valvuloplasty (p = 0.05), calicum grade (p = 0.008),echo score (p = 0.0001),preprocedure cardiac output (p = 0.03), preprocedure valve area (p = 0.0007), postprocedure mean left atrial pressure (p = 0.0001), postprocedure valve area (p = 0.0001), postprocedure valve gradient (p = 0.013), and postprocedural mitral regurgitation (p = 0.01) were statistically significant predictors of event-free survival. Additionally, the absolute and/or relative procedural change of the following variables were found to be statistically significant predictors of event-free survival: left atrial pressure (p = 0.01), valve area (p = 0.0001), and valve gradient (p = 0.02). Multivariate Cox proportional hazard analysis indicated that when only variables available before the procedure were considered, echo score (p = 0.002) and preprocedure valve area (p = 0.0002) were found to be independent predictors of event-free survival. When both pre- and postprocedure variables were considered, echo score (p = 0.002) and postprocedure valve area (p = 0.0001) were found to be independent predictors of event-free survival. In conclusion, mitral valve morphology reflected by echo score, and baseline and postprocedure mitral valve area were found to be the strongest independent predictors of event-free survival after PBMV.

Immediate and Late Outcomes after Percutaneous Mitral Co,mmissurotomy

Background:Percutaneous mitral commissurotomy(PMC) has been known as an effective therapeutic modality for moderate to severe mitral stenosis. However, long-term results and factors influencing late outcome after PMC remain to be elucidated. Materials and Methods:Three hundred and forty-six patients received PMC at Seoul National University Hospital between August, 1988 and March, 1996. We evaluated long-term results of these patients and assessed demographic, clinical, echocardiographic and hemodynamic variables in order to identify predictors of immediate and late outcomes. Results:PMC was completed without major complication or technical failure in 339(98%) out of 346 cases. A good immediate result was obtained in 67% of cases. Multivariate study identified echocardiographic score(P=0.004) and left atrial volume(P=0.009) as independent predictors of immediate outcome. The estimated 3-year and 5-year event-free survival rates were 95.8±2.5% and 90.6±4.3%, respectively. According to multivariate analysis, the independent predictors of late outcome were pre-PMC left atrial volume(P=0.03), post-PMC mitral valve area(P=0.01), and severity of mitral regurgitation after PMC(P=0.03). Conclusion:Percutaneous mitral commissurotomy as a treatment for patients with mitral stenosis is safe, and achieves good long-term results. Pre-procedural echocardiographic score, left atrial volume, post-procedural mitral valve area, and severity of mitral regurgitation affect the immediate and late outcomes after PMC.

Results of percutaneous double-balloon mitral commissurotomy in one medical center in Tunisia

Percutaneous balloon mitral commissurotomy was attempted in Tunisia, where rheumatic fever is still endemic, in 463 consecutive patients with severe rheumatic mitral valve stenosis. Their mean age ±SD was 33 ± 12 years (range 8 to 68), 324 patients (70%) were women, and 327 (71%) were in sinus rhythm. Valvotomy was technically successful in 454 patients (98%). The mean mitral valve gradient decreased from 20 ± 7 to 6 ± 4 mm Hg, mean left atrial pressure decreased from 27 ± 8 to 15 ± 6 mm Hg, cardiac index increased from 3.0 ± 0.7 to 3.6 ± 0.8 L/min/m 2, and Gorlin mitral valve area, from 0.97 ± 0.19 to 2.2 ± 0.4 cm 2 (all p < 0.001). Two-dimensional echocardiographic mitral valve area increased from 1.03 ±0.18 to 2.15 ± 0.36 cm 2 (p < 0.00001). A final valve area of ≥1.5 cm 2 was achieved in 98% of patients. Multivariate analysis identified a pre-mitral valve area <0.8 cm 2 and an echocardiographic score (echo score) ≥12 as the strongest predictors of residual stenosis (final mitral valve area <1.5 cm 2). Major procedural complications included mortality (0.4%), tamponade (0.7%), thromboembolism (2.0%), severe mitral regurgitation (4.6%), significant (pulmonary to systemic flow ratio ≥1.5) interatrial shunt (4.8%). Four hundred thirty patients were followed up between 6 and 82 months (mean 37 ± 22): 95% were in functional class I to II without reintervention, and 7 patients died (1.6%); restenosis (echocardiographic mitral valve area <1.5 cm 2) occurred in 10.4% of patients. The 3-year Kaplan-Meier freedom from restenosis was 92%, and from reintervention 93%. Because fluoroscopic calcium and postprocedure mitral valve area <-1.8 cm 2 were the independent predictors of restenosis, patients with calcified valves should be selected for this procedure on a case-to-case basis.

Percutaneous balloon mitral valvotomy for patients with mitral stenosis: Analysis of factors influencing early results

Percutaneous balloon mitral valvotomy has recently been developed as an alternative to surgical commissurotomy for patients with rheumatic mitral stenosis. We analyzed our initial experience with 60 consecutive procedures performed in 49 patients over 1 1/2 years and identified factors influencing the immediate hemodynamic results. For the total patient population, the mitral valve area increased after percutaneous mitral valvotomy from 0.8 +/- 0.04 to 1.6 +/- 0.11 cm2 (p less than 0.001). Mean diastolic mitral gradient fell from 18 +/- 1 to 7 +/- 0.4 mm Hg (p less than 0.001), and cardiac output increased from 3.8 +/- 0.2 to 4.5 +/- 0.2 L/min (p less than 0.01). Although percutaneous mitral valvotomy resulted in an increase in mitral valve area in each patient, a suboptimal result, as defined by a postprocedure mitral valve area of 1.0 cm2 or less, an increase in area of 25% or less, or a final mitral gradient of 10 mm Hg or more occurred in 21 of the 60 procedures (35%). Multivariate analysis of 16 variables was performed to determine which factors might predict this result. Patients with a suboptimal result were more likely to have severe valve leaflet thickening or immobility and an extreme degree of subvalvular thickening and calcification on echocardiogram. Other factors that predicted a suboptimal result were a smaller effective balloon dilating area and the presence of atrial fibrillation. Thus optimal immediate hemodynamic results can be obtained in the majority of patients undergoing percutaneous mitral valvotomy. Optimal results may be expected in patients in normal sinus rhythm, with pliable mitral leaflets, and with no severe subvalvular disease identified by echocardiography, who undergo dilation with large effective balloon dilating areas.