Successful Percutaneous Mitral Valvuloplasty Research Articles

Comparison of Redo percutaneous mitral valvuloplasty for mitral restenosis with first procedure for de novo mitral stenosis.

Objectives:To evaluate and compare the effects of redo percutaneous mitral valvuloplasty with initial percutaneous mitral valvuloplasty (PMV) in mitral restenosis (MR) and de novo mitral stenosis (MS) patients, respectively.Methods:A retrospective study was conducted at the cardiology department of Ch. Pervaiz Elahi Institute of Cardiology Multan for the period of one year from 6th July 2020 to 6th July 2021. A total of 50 patients were recruited in the study. Out of them, 20 de novo MS patients were placed in one group, while 30 patients with mitral restenosis, after successful initial percutaneous mitral valvuloplasty, were placed in another group. Ante grade trans-septal approach was adopted to perform percutaneous mitral valvuloplasty. The procedure was considered successful in achieving a 50% increase in the area of the mitral valve, without any major complication.Results:Procedural success in first PMV patients was more (18 patients; 90.0%) than in redo PMV patients (26 patients; 86.6%) (Non-significant). The patients in both groups didn’t differ significantly in terms of MVA after the procedure, the increase of MVA, the average difference in blood pressure across the mitral valve, and the complications experienced after the complete procedure. However, the final mitral valve area was negatively correlated with the initial area in both groups.Conclusion:Redo PMV for MR when performed after successful initial PMV is effective, has considerable rate of procedural success, which is achieved with a complication rate less as compared to initial PMV for de novo mitral stenosis.

Pulmonary artery pressure response to percutaneous mitral valvuloplasty: Associated factors and clinical implications.

Pulmonary hypertension (PH) is a marker of poor outcome in mitral stenosis (MS), which improves after percutaneous mitral valvuloplasty (PMV). However, mechanical interventions for relief of valve obstruction often but not always reduce pulmonary pressures. This study aimed to assess the parameters associated with abnormal pulmonary artery pressure (PAP) response immediately after a successful PMV, and also its impact on long-term outcome. A total of 181 patients undergoing PMV for rheumatic MS were prospectively enrolled. Invasive hemodynamic and echocardiographic measures were examined in all patients. Abnormal PAP response was defined as the mean PAP (mPAP) values unchanged at the end of the procedure. Long-term outcome was a composite endpoint of death, mitral valve replacement, repeat PMV, new onset of atrial fibrillation (AF), or stroke. The mean age was 44.1 ± 12.6 years, and 157 patients were women (86.7%). In the overall population, mPAP decreased from 33.4 ± 13.1 mmHg pre to 27.6 ± 9.8 mmHg post (p < 0.001). Following PMV, 52 patients (28.7%) did not have any reduction of mPAP immediately after the PMV. Multivariable analysis adjusting for baseline values of PAP and mitral valve area revealed that AF (Odds ratio [OR] 2.7, 95% [confidence interval] CI 1.3 to 6.7), maximum mitral valve leaflets displacement (OR 0.8, 95% CI 0.7 to 0.9), and post-procedural left ventricular compliance (OR 0.7, 95% CI 0.5 to 0.9) were predictors of a lack of improvement in mPAP. During a median follow-up of 4.4 years, the endpoint was reached in 56 patients (31%). The pulmonary pressure response to PMV was not an independent predictor of long-term events. In patients with MS undergoing PMV, pulmonary pressures may not reduce immediately after the procedure, despite adequate opening of the valve. Abnormal PAP response can be predicted from baseline clinical and valvular characteristics as well as post-procedural left ventricular compliance. The lack of any immediate reduction in mPAP is not associated with long-term adverse outcomes.

P4718Inadequate response of pulmonary artery pressure after percutaneous mitral valvuloplasty: determinant factors and prognostic impact

Abstract Introduction Pulmonary hypertension (HP) has long been known to be a marker of poor outcome in patients with mitral stenosis (MS). Percutaneous mitral valvuloplasty (PMV) is currently the treatment of choice for MS, which results in improvement in HP. However, despite the successful valve opening, the regression of PH may be incomplete. This has been attributed to irreversible morphologic changes within the pulmonary vasculature. Purpose To assess the clinical, echocardiographic and hemodynamic parameters associated with an inadequate response of the pulmonary artery pressure (PAP) immediately after a successful PMV, and also the impact of residual PH on long-term outcome in these patients. Methods 181 patients undergoing PMV for rheumatic MS were enrolled. Invasive hemodynamic and echocardiographic measures were examined in all patients. Inadequate response of PAP was defined as the mean pulmonary artery pressure (mPAP) values unchanged at the end of the procedure. Long-term outcome was a composite endpoint of death, mitral valve replacement, repeat PMV, new onset of atrial fibrillation (AF), or stroke. Results The mean age was 44.1±12.6 years, and 157 patients were women (86.7%). In the overall population, mPAP decreased from 33.4±13.1 mmHg pre to 27.6±9.8 mmHg post (p&lt;0.001), as mitral valve increased from 0.96±0.2 cm2 pre to 1.68±0.2 cm2 post (p&lt;0.001) PMV. Following PMV, 10 patients developed severe mitral regurgitation and were excluded from the analysis. Of the 171 patients analyzed, 52 (30%) did not present reduction of mPAP immediately after the PMV. Transmitral pressure gradients were significantly greater and mitral valve area was smaller in those patients with unchanged mPAP after PMV than in those whose PAP had decreased. Systolic, diastolic and mPAP pressures as well as left atrial pressure were higher in those patients who had improvement in pulmonary pressures after PMV. Multivariate analysis revealed the following independent predictors of unchanged mPAP: AF (Odds ratio [OR] 2.7, 95% [confidence interval] CI 1.1 to 6.4), mitral valve area (OR 1.3, 95% CI 1.1 to 1.5), maximum mitral valve leaflets displacement (OR 0.8, 95% CI 0.7 to 0.9), and left ventricular compliance after PMV (OR 0.8, 95% CI 0.6 to 0.9). During a mean follow-up of 28 months, the endpoint was reached in 48 patients (26%). The pulmonary pressure response to PMV was not predictor of long-term events. Conclusions In a large cohort of patients with MS undergoing PMV, mean pulmonary artery pressure values do not reduce immediately after the procedure in 30% of the cases, despite adequate opening of the valve. The factors associated with inadequate PAP response following PMV were presence of AF, larger mitral valve area, reduced valve leaflets mobility and post procedural low left ventricular compliance. The early non-reduction of mPAP after PMV is not associated with adverse outcome.

Different Characteristics, Clinical Outcomes, and Left Atrial Reverse Remodeling in Patients with Mitral Stenosis Maintaining Sinus Rhythm for at Least 10 Years after Successful Percutaneous Mitral Valvuloplasty

Background: We aimed to investigate the characteristics and echocardiographic changes in patients with severe mitral stenosis (MS) who maintained sinus rhythm (SR) for at least 10 years after successful percutaneous mitral balloon valvuloplasty (PMV). Methods: We retrospectively reviewed 107 patients who had successful PMV and follow-up echocardiography for at least 10 years without mitral valve surgery. Preprocedural, immediate postprocedural (PMV), and long-term follow-up echocardiography (at least 10 years after PMV) data were reviewed. Results: The mean follow-up time after PMV was 15 ± 4 years for SR patients (n = 50) and 16 ± 4 years (p = 0.172) for atrial fibrillation (AF) patients (n = 57). The left atrial diameter was significantly decreased in SR patients in the follow-up echocardiography images compared to its pre-PMV value (46.7 ± 6.3 vs. 43.3 ± 6.2 mm, respectively), whereas it was significantly increased in patients with AF (53.9 ± 7.1 vs. 58.1 ± 8.7 mm). In multivariate analysis, preprocedural AF (odds ratio [OR] 14.50, p = 0.001) and LA diameter ≥50 mm (OR 8.81, p < 0.001) were independently associated with increased risk for the presence of AF after successful PMV. Conclusion: Very long-term maintenance of SR after successful PMV was associated with preprocedural SR and LA diameter < 50 mm.

Left atrial compliance: an overlooked predictor of clinical outcome in patients with mitral stenosis or atrial fibrillation undergoing invasive management.

In the assessment of cardiovascular disease, the clinical significance of left atrial (LA) pressure-volume relations has largely been overlooked in contrast to left ventricular (LV) compliance. However, LA compliance has recently gained more attention. Net atrioventricular compliance (Cn), a joint measure of LA and LV compliance, can be calculated non-invasively by a previously validated method using parameters from standard echocardiography. Compliance measurement may be of relevance in selected clinical settings. First, subjects with low Cn are more likely to have their mitral valve area overestimated by the traditional mitral pressure half-time method. Consequently, low Cn in mitral stenosis, usually resulting from reduced LA compliance, can be mistaken for mild mitral stenosis. Second, low Cn independently predicted pulmonary hypertension and disease progression in medically treated mitral stenosis, and late cardiovascular complications after successful percutaneous mitral valvuloplasty. Decreased LA compliance also accounts for stiff LA syndrome, a rare complication of radiofrequency catheter ablation for atrial fibrillation, manifesting as otherwise unexplained heart failure with elevated LA pressure and pulmonary hypertension. Finally, depressed pre-ablation LA stiffness index, i.e. the ratio of the change in LA pressure to the corresponding change in LA volume during passive LA filling, was an independent predictor of arrhythmia recurrence. Thus, LA stiffening translates into adverse clinical outcomes in patients with mitral stenosis or atrial fibrillation undergoing interventional procedures. Whether reduced LA compliance after LA appendage occlusion can result in the LA stiff syndrome, has not been reported so far.

Impact of preprocedural atrial fibrillation on immediate and long-term outcomes after successful percutaneous mitral valvuloplasty of significant mitral stenosis

Optimal time to perform percutaneous mitral valvuloplasty (PMV) for patients with significant mitral stenosis (MS) and atrial fibrillation (AF) remains controversial. We sought to identify prognostic factors and evaluate long-term clinical outcomes after PMV of 77 consecutive patients with MS with a mitral valve area (MVA) <1.5 cm2. According to baseline heart rhythm, these patients were divided into sinus rhythm (SR; n = 24) and AF (n = 53) groups. The study endpoint was defined as a composite of all-cause mortality, admission for heart failure, mitral valve surgery, repeated PMV, and major cerebral vascular accident during follow-up. After successful PMV, there was no significant difference between the two groups in post-MVA and post-mitral mean pressure gradient. However, the New York Heart Association Functional Classification post-procedure was worse in the AF group (p < 0.01). In the AF group, event-free survival during follow-up was significantly lower compared with that of the SR group (p = 0.016). Independent predictors of clinical events were AF [hazard ratio (HR), 2.73; 95 % confidence interval (CI), 1.04–9.36; p = 0.03] and pulmonary artery systolic pressure (HR 2.57; 95 % CI 1.18–5.47; p = 0.017). Patients with AF at baseline were significantly associated with worse symptoms and higher event rates after successful PMV compared with those with SR. The clinical benefit of PMV may be considered for patients with MVA <1.5 cm2 before the onset of AF.

The Impact of Right Ventricular Stroke Work on B‐Type Natriuretic Peptide Levels in Patients With Mitral Stenosis Undergoing Percutaneous Mitral Valvuloplasty

We aimed to explore the relationship between brain natriuretic peptide (BNP) levels and right ventricular (RV) function in patients with mitral stenosis (MS), and to investigate the hemodynamic parameters that predict reduction of BNP levels after percutaneous mitral valvuloplasty (PMV). Few studies have evaluated BNP in the context of MS, specifically the impact of the RV stroke work (RVSW) on serum BNP levels has not been defined. Thirty patients with symptomatic rheumatic MS in sinus rhythm who were referred for a PMV were enrolled. Right and left heart pressures were obtained before and after valvuloplasty. RVSW index (RVSWI) was calculated by cardiac catheterization. Basal BNP levels were elevated in MS patients and correlated with several hemodynamic parameters including pulmonary pressure, pulmonary vascular resistance index, cardiac index (CI), and RVSWI. In multivariate analysis, CI and RVSWI were independent predictors of raised basal BNP levels. PMV resulted in a significant decrease in the RVSWI with a concurrent increase in CI (2.4 ± 0.43 to 2.9 ± 0.8 L/min/m(2), P = 0.010). Overall, plasma BNP levels significantly decreased from 124 (63/234) to 73 (48/148) pg/ml postvalvuloplasty. Multivariate analysis revealed that the reduction of left atrial (LA) pressure post-PMV was an independent predictor of change in BNP levels. Elevated baseline BNP level in MS patients was independently associated with CI and RVSWI. Plasma BNP levels were reduced after successful PMV, which was associated with the reduction of the LA pressure.

Prevalence of significant tricuspid regurgitation in patients with successful percutaneous mitral valvuloplasty for mitral stenosis: results from 12 years' follow-up of one centre prospective registry

BackgroundPercutaneous mitral valvuloplasty (PMV) is an attractive therapeutic option for mitral stenosis (MS).ObjectiveTo investigate the incidence and development of tricuspid regurgitation (TR) long after successful PMV.Design, patients and interventionsA prospective...

TCT-797: Immediate Mitral Valve Area After Successful Percutaneous Mitral Valvuloplasty: a Simple Predictor of Restenosis at Long-Term Follow Up

TCT-797: Immediate Mitral Valve Area After Successful Percutaneous Mitral Valvuloplasty: a Simple Predictor of Restenosis at Long-Term Follow Up

Left atrial remodelling in patients with successful percutaneous mitral valvuloplasty: determinants and impact on long-term clinical outcome

BackgroundLeft atrial (LA) volume is an independent prognosticator in various cardiac diseases. The authors assessed the changes of LA volume after successful percutaneous mitral valvuloplasty (PMV) and the impact of...

Immediate and Long‐Term Outcome of Redo Percutaneous Mitral Valvuloplasty: Comparison with Initial Procedure in Patients with Rheumatic Mitral Restenosis

We explored the immediate and long-term outcome of redo percutaneous mitral valvuloplasty (PMV) in a series of patients with mitral restenosis in comparison with initial PMV in the same series. We enrolled 40 consecutive patients presenting with mitral restenosis after successful initial PMV. Redo PMV was performed by the antegrade transseptal approach using either the Inoue technique or the multitrack technique. Reassessment by transthoracic echocardiography was repeated 48 hours later, and annually thereafter. Procedural success was defined as 50% or more increase of mitral valve area (MVA) with a final MVA >or=1.5 cm(2), without major complications. Restenosis was defined as loss of >50% of the initial gain of MVA by the preceding PMV with a final MVA <1.5 cm(2). Procedural success was achieved in 37 (92.5%) patients. Both the initial and redo procedures were similar concerning the final MVA and mean transmitral pressure gradient (P > 0.05 for all). The gain of MVA was higher in the initial as compared to the redo procedure (P < 0.001). The initial mitral valve score correlated negatively with the final MVA in both the initial and redo procedures, and was the only independent predictor of the time to redo procedure, by multivariate regression analysis. At long-term follow-up (61 +/- 2.8 months), the mean MVA was 1.6 +/- 0.3 cm(2). Three patients--out of 12 available for follow-up--developed restenosis. Redo PMV for mitral restenosis is feasible, safe, and achieves immediate and long-term outcome comparable to initial PMV.

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

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

Right atrial wall hematoma following percutaneous mitral valvuloplasty

A 50-year-old male underwent successful percutaneous mitral valvuloplasty for restenosis after surgical commissurotomy. Trans-septal puncture was difficult. Following the procedure, the patient developed chest pain and signs of systemic venous congestion, yet no hemodynamic collapse. Echocardiographic evaluation revealed a cystic mass compressing the right atrium, not communicating with the atrial cavity, mostly an intramural hematoma. The case was managed conservatively, and serial echocardiographic follow-up showed gradual reduction in size until ultimate disappearance of the mass 1 month later. In conclusion, right atrial intramural hematoma is a possible complication of mitral valvuloplasty, readily detected by echocardiography, and amenable for conservative management.

Evolução da onda P do eletrocardiograma após valvoplastia mitral em pacientes portadores de sobrecarga atrial esquerda

To investigate potential clinical, echocardiographic and/or hemodynamic predictors of the regression of electrocardiographic (ECG) signs of left atrial enlargement (LAE) after successful percutaneous mitral valvuloplasty (PMV).We studied 24 patients (75% female, mean age =37.1 +/- 11.9 years) with moderate to severe mitral stenosis (MS), sinus rhythm (SR) and ECG signs of LAE who underwent successful PMV between 2002 and 2004. At least 6 months after the procedure (388.2 +/- 192.9 days), the patients returned for clinical, ECG and echocardiographic follow-up. They were then divided in 2 groups: patients of group 1 (n = 8; 33.3%) still had ECG signs of LAE, and patients of group 2 (n = 16; 66.6%), had normal P wave. A multivariate analysis of clinical, ECG, echocardiographic and hemodynamic variables was performed.The mitral valve area (MVA) increased from 1.12 +/- 0.15 cm2 to 1.9 +/- 0.35 cm2 immediately after the procedure (p < 0.0001) and decreased to 1.89 +/- 0.41 cm2 at follow-up (p = NS). Left atrium diameter decreased from 48 +/- 2.9 mm pre-procedure to 43 +/- 4.8 mm at follow-up (p = 0.0001). P-wave duration decreased from 0.12 +/- 0.01 sec pre-PMV to 0.09 +/- 0.02 sec at follow-up (p = 0.0001). An MVA > or = 1.7 cm2 at follow-up was the only independent predictor of a normal P-wave after PMV (p=0.02).ECG changes suggestive of LAE regress in the majority of patients with MS and sinus rhythm that undergo a successful PMV. An MVA > or = 1.7 cm2 at late follow-up was found to be an independent predictor of such normalization.

Follow-Up Assessment after Percutaneous Mitral Valvuloplasty (PMV) with Inoue Balloon

Background:Percutaneous Mitral Valvuloplasty (PMV) is the first-line treatment modality in selected patients with symptomatic mitral stenosis and more recently available Inoue single-balloon catheter technique produces good results with low incidence of complications. The purpose of this study was to evaluate the immediate and over 6 months follow-up results after successful PMV with an Inoue balloon and to identify the predictive factors for the results. Methods:From May 1995 to Feburary 1997, a PMV with an Inoue balloon was technically successful in 114 (95%) of the 119 patients treated at the Sejong General Hostpital. In this study, a series of echocardiographic follow-up were performed in 54 patients with rheumatic mitral stenosis, at least 6 months after their successful PMV. In PMV, the inflation was conducted in steps, starting with a recommended maximum size of balloon by the Inoue criteria. After each inflation, the mitral valve opening and competence were evaluated by Transesophageal echocardiography (TEE) and continuing increase balloon size. Results:Echocardiographic follow-up assessment was performed in 54 patients serially in a interval of 3 months or 6 months. Their mean age was 46±11 years (24 to 66 years) and the mean total echocardiographic score was 7.1±1.6. A optimal result was obtained in 95% of the cases (51/54). The post-PMV mitral valve area increased to 1.95±0.37 cm and 1.79± 0.28 cm by 2-D and Doppler method, the average transmitral mean diastolic pressure gradient decreased to 5.16±2.8 mmHg and LA pressure was decreased to 11.28±8.2 mmHg. The newly developed and aggravated mitral regurgitation was observed in 17 patients (31.5%). The restenosis was noted in 2 cases (3.7%) after 1 year follow-up. The pre-procedural echocardiographic score for leaflet mobility, thickening and calcification was more higher in patients with restenosis. There was significant tendency of decrement in the mitral valve area in patients with a echocardiographic score>8 compared with those≤8 over 6 months after the PMV. Conclusion: PMV with the Inoue balloon under TEE guide as a combined treatment modality of patient with symptomatic mitral stenosis is relatively safe and achieves good immediate and midterm follow-up results. The echocardiographic score is considered as useful predictor of midterm results and restenosis after PMV with Inoue balloon. (Korean Circulation J 1998;28(11):1841-1851)

Left Ventricular Ejection Performance Before and Following Percutaneous Mitral Valvuloplasty in Mitral Stenosis

Background:In cases of pure mitral stenosis, it is known that the impairment of left ventricular (LV ejection performance is frequently accompanied, but long term follow up studies on the LV ejection performance after successful percutaneous mitral valvuloplasty are rare so far. Methods:An prospective investigation was performed on 32 cases of patients, 10 being male and 22 female, who have been maintained after successful percutaneous mitral valvuloplasty of pure mitral stenosis. The LV ejection performances have been measured with cardiomechanography and echocardiography before and following the procedure, and the follow-up periods were 24 months in average, in the range of 12 to 35 months. Results:The stroke volume, cardiac output, cardiac index, ejection fraction, mean velocity of circumferential shortening and fractional shortening(FS, which are indices of LV ejection performance, all increased in follow-up than before procedure. In addition, LV end-diastolic dimension and LV end-diastolic dimension index, which are indices of LV preload, increased, and the end-systolic LV wall stress which is an index of afterload, decreased. And the ratio of measured FS to expected FS, which is an index of myocardial contractility, increased in follow-up. Conclusion:The successful percutaneous mitral valvuloplasty of pure mitral stenosis is found to improve LV ejection performance in long term by increasing preload, decreasing afterload, and incr- easing myocardial contractility of left ventricle.

Left-to-right atrial shunting after percutaneous mitral valvuloplasty. Incidence and long-term hemodynamic follow-up.

To assess the incidence and long-term evolution of left-to-right atrial shunting (AS) after the performance of percutaneous mitral valvuloplasty (PMV), venovenous indicator dilution curves and right heart oximetric measurements were obtained in 68 consecutive patients before and after successful PMV. The procedure increased the mitral valve area (p less than 0.0001) and decreased the mitral gradient (p less than 0.0001). No AS was detected before PMV, but it was detected immediately after PMV. Oximetry identified AS in 17 patients (25%), and dilution curves identified AS in an additional 25 (total, 62%). The ratio of mean pulmonary to systemic blood flow (Qp/Qs) was 1.31 +/- 0.2, and in six patients (9%), the ratio was 1.5 or greater. Among nine clinical, 20 hemodynamic, and six procedural variables, stepwise logistic regression analysis selected the following as independent predictors of AS: smaller increases in valve area (p = 0.01) after PMV, absence of previous surgical commissurotomy (p = 0.02), mitral valve calcification (p = 0.02), and smaller left atria (p = 0.06). Among the 33 patients recatheterized at 6 months, oximetry had detected AS in 10, and dilution curves detected AS in an additional nine (total, 58%) immediately after PMV. At 6 months, AS had decreased or disappeared in 14 of these patients (74%), had increased in three (16%), and was unchanged in two (10%). Overall, at 6 months, oximetry identified AS in three patients, and dilution curves identified AS in an additional 13 (total, 48%). AS was detected at 6 months in only three patients but was not detected immediately after PMV. Although AS is very frequent immediately after PMV, Qp/Qs is usually less than 1.5. The appearance of shunting correlates with patient characteristics and with less improvement in valve area after PMV. Atrial shunting usually persists at 6 months, but its severity almost always decreases.