Surgical Commissurotomy Research Articles

Outcome of Surgical Commissurotomy for Aortic Valve Stenosis in Early Infancy

The method of treatment of aortic valve stenosis in early infancy is still controversial. This study was performed to evaluate short-term and long-term outcome in our center during a 14-year period. Between 1991 and 2004, 64 consecutive patients younger than 3 months old underwent open surgical commissurotomy because of aortic valve stenosis. Median age was 18 days (range, 1 to 79 days), and median weight was 3.6 kg (range, 1.9 to 6.7 kg). Left ventricular function was good in 44 patients (69%), depressed in 12 (19%), and poor in 8 (12%). The study ended in July 2005. Median follow-up time was 4.1 years (range, 0.4 to 13.6 years). The 30-day mortality was 3 of 64 patients and late mortality was 3 of 61, and the respective mortality in patients younger than 1 month old was 2 of 41 and 2 of 39. There was no early mortality after 1993 and no late mortality after 1999. Thirteen patients required reoperation. Median time to reoperation was 4.3 years (range, 0.2 to 11.3 years) and to aortic valve replacement (7 Ross and 1 homograft) was 6.9 years (range, 1.6 to 9.7 years). At the last follow-up, all had good left ventricular function and 57 of 58 had an ability index of 1. Surgical commissurotomy for aortic valve stenosis during the first 3 months of life can be done with low mortality and morbidity. The risk for early recurrent stenosis or regurgitation is low, and the need for aortic valve replacement can, in most cases, be delayed until the child is older. The long-term functional ability is excellent.

Surgical strategy for the bicuspid aortic valve: Tricuspidization with cusp extension versus pulmonary autograft

The congenitally bicuspid aortic valve is the most common etiologic factor associated with clinically significant aortic stenosis and/or regurgitation in pediatric patients. Beyond infancy, surgical intervention typically involves valve repair with cusp thinning and commissurotomy or valve replacement, primarily with pulmonary autograft in the current era. An aortic valve repair technique using tricuspidization with cusp extension was introduced in 1999. This study compares the midterm clinical outcome in patients undergoing valve repair by tricuspidization with cusp extension with those receiving a pulmonary autograft (Ross). A retrospective study was performed on all consecutive patients with symptomatic bicuspid aortic valve disease who underwent tricuspidization with cusp extension or a Ross procedure between 1999 and 2005. In both groups, all patients were at least 1 year of age at time of the operation. During this period, 21 children (median age 12.6 years, range 2.6-18 years) underwent tricuspidization with cusp extension (TCE group) and 25 children (median age 10.2 years, range 11.5 months-20.1 years) underwent the Ross procedure. Prior balloon valvuloplasty was performed in 5 (24%) of the children in the TCE group and 16 (64%) of the children in the Ross group. Prior surgical commissurotomy was performed in 4 (19%) TCE patients and in 9 (36%) Ross patients. During a median follow-up period of 36.4 months (range 2.5 months-7.4 years), 2 (10%) patients in the TCE group required valve-preserving early revision of the repair, 2 (10%) TCE patients required subsequent aortic valve replacement at 16 and 33 months, 1 (4%) Ross patient required subsequent valve repair at 5 years, and 1 (4%) Ross patient underwent cardiac transplantation at 46 months. At 36 months, the actuarial freedom from reintervention on the aortic valve or autograft was 90% in the TCE group, with 11 patients at risk, and 100% in Ross patients, with 13 patients at risk (P = .39); the freedom from moderate valve dysfunction or reintervention was 66% for TCE patients and 95% for Ross patients (P = .07). There were no deaths, and all but 1 Ross patient remain in New York Heart Association class I. Reintervention rates in patients undergoing tricuspidization with cusp extension or a primary Ross procedure are similar. Valve performance in the TCE group is satisfactory at midterm follow-up, but the Ross repair appears to provide greater stability of valve function. These results suggest that repair with valve tricuspidization and cusp extension provides reliable palliation of the symptomatic bicuspid aortic valve.

Percutaneous mitral balloon valvotomy

Percutaneous mitral balloon valvotomy (PMBV) was introduced in 1984 by Inoue who developed the procedure as a logical extension of surgical closed commissurotomy. Since then, PMBV has emerged as the treatment of choice for severe pliable rheumatic mitral stenosis (MS). With increasing experience and better selection of patient, the immediate results of the procedure have improved and the rate of complications declined. When the reported complications of PMBV are viewed in aggregate, complications occur at approximately the following rates: mortality (0-0.5%), cerebral accident (0.5-1%), mitral regurgitation (MR) requiring surgery (1.6-3%). These complication rates compare favorably to those reported after surgical commissurotomy. Several randomized trials reported similar hemodynamic results with PMBV and surgical commissurotomy. Restenosis after PMBV ranges from 4 to 70% depending on the patient selection, valve morphology, and duration of follow up. Restenosis was encountered in 21% of the author's series at mean follow-up 6 +/- 4.5 years and the 10 and 15 years restenosis-free survival rates were (70 +/- 3)% and (44 +/- 5)%, respectively, and were significantly higher for patients with favorable mitral morphology (85 +/- 3% and 65 +/- 6%), respectively (P < 0.0001). The 10 and 15 years event-free survival rates were (79 +/- 2)% and (43 +/- 9)% and were significantly higher for patients with favorable mitral morphology (88 +/- 2)% and (66 +/- 6)%, respectively (P < 0.0001). The effect of PMBV on severe pulmonary hypertension, concomitant severe tricuspid regurgitation, left ventricular function, left atrial size, and atrial fibrillation are addressed in this review. In addition, the application of PMBV in specific clinical situations such as in children, during pregnancy and for restenosis is discussed.

Immediate and Long-Term Results of Mitral Balloon Valvotomy for Restenosis Following Previous Surgical or Balloon Mitral Commissurotomy

Immediate and Long-Term Results of Mitral Balloon Valvotomy for Restenosis Following Previous Surgical or Balloon Mitral Commissurotomy

Current status of percutaneous valvular procedures

During the past few decades, percutaneous valvular procedures have been used in mitral and aortic stenosis. Percutaneous mitral commissurotomy, which has virtually replaced surgical commissurotomy in the treatment of mitral stenosis, has been performed since the mid-1980s and has provided good results in thousands of patients worldwide. Percutaneous balloon aortic valvuloplasty has largely been abandoned due to its limited efficacy and the risks involved. New percutaneous procedures are currently being developed in mitral regurgitation and aortic stenosis, which represent the two most frequent valve diseases in industrialized countries. They are in the early stages of development but have opened a very exciting field of investigation. Two percutaneous mitral valve treatment techniques have been used: the edge-to-edge technique and the prosthetic ring annuloplasty. Preliminary series show that they are feasible; however, they need to be further evaluated in comparison with contemporary treatment to accurately assess their effectiveness and the risks involved. Since 2003, percutaneous aortic valve replacement has been performed in approximately 100 compassionate cases with end-stage aortic stenosis, formally declined for surgery. It results in hemodynamic and clinical improvement, with an acceptable risk in this highly selected population. The evaluation of these new percutaneous procedures requires a close collaboration between interventionalists, echocardiographers, engineers, and surgeons. It is probable that they will play an important role in the treatment of valve disease in the future.

Neonatal Surgical Aortic Commissurotomy: Predictors of Outcome and Long-Term Results

The objective of this study was to review our institutional experience concerning neonatal aortic commissurotomy and to identify predictors of outcome. From January 1, 1990, to January 1, 2005, 65 neonates were referred for critical aortic stenosis. Among these 36 consecutive patients underwent surgical valvotomy by the same surgeon and 16 patients had balloon valvotomy. We examined clinical records to establish determinants of outcome and illustrate long-term results. In the surgical group 6 patients had nonstenotic parachute mitral valve, 6 had aortic coarctation, 13 had endocardial fibroelastosis; and 15 had depressed fractional shortening. In the balloon valvotomy group most infants had associated mitral stenosis (n = 7), small aortic annulus (n = 5), multiple anomalies (n = 2), endocardial fibroelastosis (n = 9), and depressed fractional shortening (n = 13). In the surgical group global mortality was 19%; 47% in infants with depressed fractional shortening and 0% in infants with normal fractional shortening. Mortality in the balloon valvotomy group was 56%. Low fractional shortening, low mean aortic gradient, endocardial fibroelastosis, and small aortic annulus were associated with fatal outcome. In the surgical group 6 patients needed Ross operation at a median interval of 4 years from commissurotomy. In the balloon valvotomy group 3 patients needed early mitral replacement and 5 aortic valve surgery. At a median follow-up of 6 years, all children are in New York Heart Association class I, all have a normal ventricular function, 2 have aortic restenosis, and 5 have at least moderate aortic incompetence. In a selected population of neonates with isolated aortic stenosis, surgical valvotomy offers an excellent long-term outcome to patients with a normokinetic left ventricle, while patients with a hypokinetic left ventricle have a poor outcome. Balloon valvotomy offers poor results when performed in patients with complex anomalies.

Resultados da valvoplastia por balão do grupo submetido a plastia mitral percutânea ou cirúrgica prévias com o tratado pela primeira vez: evolução do grupo com plastia prévia

To evaluate 501 procedures of mitral balloon valvuloplasty and the differences among the group already submitted the prior surgical or balloon valvuloplasty, with 59 procedures and the group without previous intervention, with 442 procedures. It was used the single balloon in 403, Inoue balloon in 89 and a double balloon in six, with no difference between the 2 groups (p=0.6610). The prior surgical or balloon valvuloplasty group was older, with higher echo score and higher atrial fibrillation rate and of its 59 patients, 48 had been submitted only to mitral surgical commissurotomy, 8 only to mitral balloon valvuloplasty and 3 to surgical commissurotomy and after submitted to balloon valvuloplasty because of restenosis. In prior surgical or balloon valvuloplasty and mitral balloon valvuloplasty without previous intervention groups pre valvuloplasty there were respectively: echo mitral valve area 0.99+/-0.21 and 0.94+/-0.21 cm2 (p=0.0802) and mitral valve area (Gorlin) 0.94+/-0.18 and 0.91+/-0.21 cm2 (p=0.2518) and post mitral valvuloplasty 1.95+/-0.44 and 2.05+/-0.42 cm2 (p=0.1059). The hemodynamic and angiographic outcome of the prior surgical or balloon valvuloplasty group were similar to the group without previous intervention. The evolution was satisfactory in the prior valvuloplasty subgroup with long-term follow-up.

Immediate and Long-Term Results of Mitral Balloon Valvotomy for Restenosis Following Previous Surgical or Balloon Mitral Commissurotomy

This study compared immediate with long-term results of mitral balloon valvotomy (MBV) in patients who underwent MBV as an initial procedure versus those who underwent repeat MBV. Fifty-six patients who were a mean age of 28 +/- 8.8 years (group A) and had mitral restenosis after surgical or balloon commissurotomy underwent MBV and were compared with 524 patients who were a mean age of 31 +/- 11 years (group B) and underwent MBV as an initial procedure. Prospective data obtained included demographic, hemodynamic, echocardiographic, and clinical follow-up for 0.5 to 15 years after MBV. No deaths or technical failure were encountered after MBV. Mitral regurgitation >2/4 occurred in 1 patient (2%) in group A and in 9 patients (2%) in group B (p = 0.24). Fifty-two of 56 patients (93%) in group A had good immediate results (mitral valve area >or=1.5 cm(2), mitral regurgitation <2/4), as did 504 of 524 patients (96%) in group B (p = 0.4). Actuarial values for freedom from restenosis at 10 years were 58 +/- 7% for group A versus 69 +/- 3% for group B (p = 0.18). Ten-year event-free survival rate was 54 +/- 7% for group A versus 80 +/- 3% for group B (p <0.005). The predictors of event-free survival were age (p = 0.003), echocardiographic score (p <0.0001), and baseline atrial fibrillation (p = 0.01). In conclusion, MBV is safe and provides good immediate results in patients who have restenosis. Long-term results are inferior compared with de novo mitral stenosis but is still satisfactory. More than 50% of patients remained improved at 10 years, thus enabling the operation or reoperation to be deferred.

Percutaneous valve procedures: what is the future?

Since its introduction 27 years ago by Andreas Gruntzig, interventional cardiology has expanded its scope from coronary disease to peripheral, congenital, and also valve diseases.Percutaneous mitral commissurotomy and aortic valvuloplasty have been performed since the mid 1980s. Balloon commissurotomy has been used in tens of thousands of patients worldwide and provides good short- and long-term results in a wide range of patients. It has virtually replaced surgical commissurotomy in the management of mitral stenosis. On the other hand, percutaneous aortic valvuloplasty is almost abandoned worldwide due to its lack of efficacy and the risks involved. The new techniques of percutaneous valve intervention are aortic valve replacement, and mitral valve repair. Both are at an early stage since the first in-man applications only started in 2002. Preliminary series show that these techniques are feasible; however, they must be further evaluated in comparison with contemporary treatment to accurately assess efficacy and risks. Today potential applications concern high-risk patients, however, after thorough evaluation this may be extended to others in the future. Therefore, percutaneous interventions already play an important role in management of valvular heart disease, which is likely to grow in the future.

Percutaneous valve procedures: Present and future

Percutaneous mitral commissurotomy and aortic valvuloplasty have been being performed since the mid-1980s. Balloon commissurotomy has been used in thousands of cases worldwide and it provides good short- and long-term results in a wide range of patients. It has virtually replaced surgical commissurotomy in the treatment of mitral stenosis. In contrast, percutaneous aortic valvuloplasty is almost abandoned worldwide due to its lack of efficacy and the risks involved. The new techniques of percutaneous valve intervention: aortic valve replacement and mitral valve repair are at an early stage: the first in-man applications of these fledgling techniques started in 2002. Preliminary series show that they are feasible; however, they need to be further evaluated in comparison with contemporary treatment to assess accurately how efficient they are and the risks involved. Currently potential applications concern high-risk patients, however, in the future, after thorough evaluation, this may be extended to others. Thus, percutaneous interventions already play an important role in treatment of valvular heart disease, a role that seems set for future expansion.

Natural history of mitral stenosis and echocardiographic criteria and pitfalls in selecting patients for balloon valvuloplasty.

In summary, MS is a progressive disease characterized by a long latent period between the initial attack of acute rheumatic fever and the development of symptoms. For patients with MS who require mechanical relief of obstruction PMV is the preferred treatment and gives results comparable to surgical commissurotomy. Two-dimensional echocardiographic assessment of mitral valve morphology is the most important predictor of outcome. An echocardiographic score <8 predicts good immediate and long-term results. In patients undergoing PMV, TEE is useful for detecting left atrial and left atrial appendage thrombi, guiding transseptal puncture, assessing results and detecting complications.

Effectiveness of percutaneous mechanical mitral commissurotomy using the metallic commissurotome in patients with restenosis after balloon or previous surgical commissurotomy

Balloon mitral valvuloplasty has been reported to give equal or less positive results after previous commissurotomy than after a first procedure. Percutaneous mechanical mitral commissurotomy (PMMC) is a new technique that has not yet been evaluated in this subset of patients. Of 1,175 PMMC procedures (1,175 patients), 173 patients (14.7%) had previous commissurotomy; patients were older (40 vs 35 years of age, p <0.0001) and more often in atrial fibrillation (34% vs 21%, p = 0.0016) than were patients who had not undergone previous commissurotomy. The baseline transmitral gradient was lower (17 ± 8 vs 19 ± 8 mm Hg, p <0.002) and the echocardiographic Wilkins score was higher (8.7 ± 1.9 vs 7.6 ± 1.8, p <0.0001) for patients who underwent previous commissurotomy. Baseline mitral valve area was comparable between the 2 groups (0.96 ± 0.21 vs 0.93 ± 0.24 cm 2). Immediate results were satisfactory, although slightly less favorable after previous commissurotomy, with a final mitral valve area of 2.01 ± 0.30 versus 2.12 ± 0.36 cm 2 (p <0.0001), and a residual transvalvular gradient of 5.0 ± 3.6 versus 4.2 ± 4.1 mm Hg (p = 0.003). The rates of procedural success (93%) and severe complications (4.7%) were comparable between the 2 groups. Thus, PMMC is an effective and safe technique for the treatment of mitral restenosis after previous commissurotomy.

Which Patients Benefit From Percutaneous Mitral Balloon Valvuloplasty?

Percutaneous mitral balloon valvuloplasty (PMV) results in good immediate results, particularly in patients with echocardiographic scores (Echo-Sc) < or =8. However, which variables relate to long-term outcome is unclear. We report the immediate and long-term clinical follow-up (mean, 4.2+/-3.7 years; range, 0.5 to 15) of 879 patients who underwent 939 PMV procedures. Patients were divided into 2 groups, Echo-Sc < or =8 (n=601) and Echo-Sc >8 (n=278). PMV resulted in an increase in mitral valve area from 1.0+/-0.3 to 2.0+/-0.6 cm2 in patients with Echo-Sc < or =8 and from 0.8+/-0.3 to 1.6+/-0.6 cm2 in patients with Echo-Sc >8 (P<0.0001). Although adverse events (death, mitral valve surgery, and redo PMV) were low within the first 5 years of follow-up, a progressive number of events occurred beyond this period. Nevertheless, survival (82% versus 57%) and event-free survival (38% versus 22%) at 12-year follow-up was greater in patients with Echo-Sc < or =8 (P<0.0001). Cox regression analysis identified post-PMV mitral regurgitation > or =3+, Echo-Sc >8, age, prior surgical commissurotomy, NYHA functional class IV, pre-PMV mitral regurgitation > or =2+, and higher post-PMV pulmonary artery pressure as independent predictors of combined events at long-term follow-up. The immediate and long-term outcome of patients undergoing PMV is multifactorial. The use of the Echo-Sc in conjunction with other clinical and morphological predictors of PMV outcome allows identification of patients who will obtain the best outcome from PMV.

Effects of percutaneous mitral balloon valvuloplasty on P-wave dispersion in patients with mitral stenosis

P-wave dispersion (PWD) is a new electrocardiographic marker that has been associated with inhomogeneous and discontinuous propagation of sinus impulses. 1 Dilaveris P.E Gialafos E.J Andrikopoulos G.K Richter D.J Papanikolaou V Poralis K Gialafos J.E Clinical and electrocardiographic predictors of recurrent atrial fibrillation. Pacing Clin Electrophysiol. 2000; 23: 352-358 Crossref PubMed Scopus (201) Google Scholar , 2 Dilaveris P.E Gialafos E.J Sideris S Theopistou A.M Andrikopoulos G.K Kyriakidis M Gialafos J.E Toutouzas P.K Simple electrocardiographic markers for the prediction of paroxysmal idiopathic atrial fibrillation. Am Heart J. 1998; 135: 733-738 Abstract Full Text Full Text PDF PubMed Scopus (570) Google Scholar It can be defined as the difference between maximum and minimum P-wave duration. The prolongation of intra-atrial and interatrial conduction time, and the inhomogeneous propagation of sinus impulses are well known electrophysiologic characteristics of the atrium prone to fibrillate. 1 Dilaveris P.E Gialafos E.J Andrikopoulos G.K Richter D.J Papanikolaou V Poralis K Gialafos J.E Clinical and electrocardiographic predictors of recurrent atrial fibrillation. Pacing Clin Electrophysiol. 2000; 23: 352-358 Crossref PubMed Scopus (201) Google Scholar , 2 Dilaveris P.E Gialafos E.J Sideris S Theopistou A.M Andrikopoulos G.K Kyriakidis M Gialafos J.E Toutouzas P.K Simple electrocardiographic markers for the prediction of paroxysmal idiopathic atrial fibrillation. Am Heart J. 1998; 135: 733-738 Abstract Full Text Full Text PDF PubMed Scopus (570) Google Scholar Furthermore, prolonged P-wave duration and increased PWD have been reported to carry an increased risk for atrial fibrillation (AF). 2 Dilaveris P.E Gialafos E.J Sideris S Theopistou A.M Andrikopoulos G.K Kyriakidis M Gialafos J.E Toutouzas P.K Simple electrocardiographic markers for the prediction of paroxysmal idiopathic atrial fibrillation. Am Heart J. 1998; 135: 733-738 Abstract Full Text Full Text PDF PubMed Scopus (570) Google Scholar , 3 Aytemir K Ozer N Atalar E Sade E Aksoyek S Ovunc K Oto A Ozmen F Kes S P wave dispersion on 12-lead electrocardiography in patients with paroxysmal atrial fibrillation. Pacing Clin Electrophysiol. 2000; 23: 1109-1112 Crossref PubMed Scopus (244) Google Scholar Rheumatic mitral stenosis (MS) is frequently seen in developing countries and causes significant morbidity and mortality. 4 Braunwald E Valvular heart disease. in: Braunwald E Zipes D.P Libby P Heart Disease A Textbook of Cardiovascular Medicine. 6th ed. WB Saunders, Philadelphia2001: 1643-1653 Google Scholar Percutaneous mitral balloon valvuloplasty (PMBV) is the procedure of choice in patients who have symptomatic, hemodynamically severe MS, and are suitable for this procedure. 4 Braunwald E Valvular heart disease. in: Braunwald E Zipes D.P Libby P Heart Disease A Textbook of Cardiovascular Medicine. 6th ed. WB Saunders, Philadelphia2001: 1643-1653 Google Scholar , 5 Inoue K Owaki T Nakamura T Kitamura F Miyamoto N Clinical application of transvenous mitral commissurotomy by a new balloon catheter. J Thorac Cardiovasc Surg. 1984; 87: 394-402 PubMed Google Scholar , 6 Reyes V.P Raju B.S Wynne J Stephenson L.W Raju R Fromm B.S Rajagopal P Mehta P Singh S Rao D.P Percutaneous balloon valvuloplasty compared with open surgical commissurotomy for mitral stenosis. N Engl J Med. 1994; 331: 961-967 Crossref PubMed Scopus (344) Google Scholar This procedure is highly successful with a low complication rate and significant short- and long-term improvement in hemodynamics and symptoms. 7 McKay C.R Kawanishi D.T Kotlewski A Parise K Odom-Maryon T Gonzalez A Reid C.L Rahimtoola S.H Improvement in exercise capacity and exercise hemodynamics 3 months after double-balloon, catheter balloon valvuloplasty treatment of patients with symptomatic mitral stenosis. Circulation. 1988; 77: 1013-1024 Crossref PubMed Scopus (80) Google Scholar , 8 Block P.C Palacios I.F Block E.H Tuzcu E.M Griffin B Late (two-year) follow-up after percutaneous balloon mitral valvotomy. Am J Cardiol. 1992; 69: 537-541 Abstract Full Text PDF PubMed Scopus (50) Google Scholar The objectives of this study were (1) to identify PWD in patients with MS, and (2) to determine the effects of PMBV on PWD. There is currently no study on the effects of MS and PMBV on PWD.

Influence of the echocardiographic score and not of the previous surgical mitral commissurotomy on the outcome of percutaneous mitral balloon valvuloplasty

To evaluate prior mitral surgical commissurotomy and echocardiographic score influence on the outcomes and complications of percutaneous mitral balloon valvuloplasty. We performed 459 complete mitral valvuloplasty procedures. Four hundred thirteen were primary valvuloplasty and 46 were in patients who had undergone prior surgical commissurotomy. The prior commissurotomy group was older, had higher echo scores, and a tendency toward a higher percentage of atrial fibrillation. When the groups were compared with each other, no differences were found in pre- and postprocedure mean pulmonary artery pressure, mean mitral gradient, mitral valve area, and mitral regurgitation. Because we found no significant differences, we subdivided the entire group based on echo scores, those with echo scores < or =8 and those with echo scores >8 the mitral valve area being higher in the < or =8 echo score group 2.06+/-0.42 versus 1.90+/-0.40 cm2 (p=0.0090) in the >8 echo score group. Dividing the groups based on echo score revealed that the higher echo score group had smaller mitral valve areas postvalvuloplasty.

Inoue balloon mitral valvuloplasty: long-term clinical and echocardiographic follow-up of a predominantly unfavourable population

To assess long-term outcome in a typical Western population of predominantly unfavourable patients undergoing Inoue balloon mitral valvuloplasty. Outcome amongst patients has only been undertaken in the medium term. Long-term echocardiographic data in particular are scarce. Inoue mitral valvuloplasty was attempted in 106 patients. There were six technical failures; the procedure was therefore completed in 100 patients, who underwent annual clinical and echocardiographic follow-up. Patients were aged 63.5+/-10. 3 years. 82% were female. Unfavourable characteristics included age >65 (52%), NYHA class III or IV (87%), >/=1 significant co-morbidity (63%), atrial fibrillation (82%), previous surgical commissurotomy (25%) and echocardiographic score >8 (59%, mean 8.9+/-2.1). Mitral valve area increased from 0.98+/-0.23 to 1.54+/-0.31 cm(2). There were three major complications. Post-procedure, symptoms improved in 88% of patients. Haemodynamic success (mitral valve area increase >50%, final mitral valve area >1.5 cm(2), mitral regurgitation </=grade 2) was achieved in 61% of cases. Mean follow-up was 4.3+/-1. 4 years. Survival was 97%, 88% and 82% at 1, 3 and 6 years. Event-free survival (freedom from death, mitral valve replacement or repeat valvuloplasty) was 96%, 82% and 56% at 1, 3 and 6 years. Freedom from restenosis (loss of >50% gain in mitral valve area, mitral valve area <1.5cm (2)) was 98%, 92% and 75% at 1, 3 and 6 years. Pre-procedural predictors of event-free survival were male sex, absence of co-morbidities, lower echocardiographic score and smaller left atrial diameter. In a Western population with predominantly unfavourable characteristics for mitral valvuloplasty, long-term outcome post-procedure is reasonable. A moderate increase in mitral valve area can be achieved at low procedural risk, and the subsequent rate of restenosis is low. Nonetheless, 6 years after the procedure, half of the patients will have required further intervention or died. For fitter patients willing to accept significant operative risk, mitral valve replacement remains a valuable alternative.

Percutaneous Suture Closure for Management of Large French Size Arterial and Venous Puncture

Aortic valvuloplasty procedures have been limited principally by the occurrence of restenosis in this patient population. Once a decision has been made to proceed with aortic valvuloplasty, one of the next major concerns is management of the femoral artery puncture. For these procedures, 12Fr and 14Fr sheath introducers and prolonged compression with clamps or hemostatic devices have been necessary. Prolonged immobilization is painful for the elderly population in whom aortic valvuloplasty is used. The ability to use percutaneous suture closure to eliminate the need for manual compression, especially for clamp or hemostatic devices, has greatly improved patient tolerance for these procedures. A technique for preloading the suture closure device prior to insertion of a large bore sheath is the technique of choice to make this possible. Mitral valvuloplasty has faced fewer limitations and of course yields results equivalent to surgical commissurotomy in randomized trials. Improved management of the 14Fr femoral venous site has made outpatient treatment simpler. The technical approach necessary for success in the venous system uses contrast injections through the Perclose device marker port to insure that the device is properly positioned prior to deployment of the sutures. More rapid immobilization and simplified postprocedural management can be achieved using percutaneous suture closure for large caliber sheaths after mitral and aortic valvuloplasty.

Rheumatic Mitral Stenosis.

Patients with symptomatic mitral stenosis should undergo evaluation with transthoracic and transesophageal echocardiography (Table 1). Those patients with suitable valve morphology should be treated with percutaneous transvenous mitral commissurotomy (PTMC). Randomized trials of catheter commissurotomy have shown no differences in long-term outcome compared with surgical commissurotomy; there is therefore no role for surgical commissurotomy in patients who are suitable candidates for balloon commissurotomy. Mitral valve replacement should be recommended for those patients with valve deformity too severe to undergo catheter therapy. Some older patients who are less-than-ideal candidates for catheter therapy nonetheless may benefit from it as a palliative alternative to otherwise high-risk valve surgery. Asymptomatic patients should be screened for the presence of pulmonary artery hypertension. Those who have pulmonary artery systolic pressure at rest of greater than 50 mm Hg or who develop pulmonary artery systolic pressure of greater than 60 mm Hg with exercise should be considered for PTMC.

Percutaneous mitral commissurotomy for restenosis after surgical commissurotomy: Late efficacy and implications for patient selection

OBJECTIVESThe results of percutaneous mitral commissurotomy were assessed in patients with restenosis after surgical commissurotomy.BACKGROUNDBalloon dilation is feasible in patients with restenosis after surgical commissurotomy, but little is known about its late efficacy.METHODSWe studied 232 patients who had undergone percutaneous mitral commissurotomy a mean of 16 ± 8 years after surgical commissurotomy. Mean age was 47 ± 14 years; 81 patients (35%) had valve calcification. All patients had restenosis with bilateral commissural fusion as assessed by echocardiography. Technical failure occurred in 9 patients and the procedure used a single balloon in 7 patients, a double balloon in 95, and the Inoue balloon in 121.RESULTSComplications were death in 1 patient (0.4%) and mitral regurgitation >2/4 in 10 (4%); 191 patients (82%) had good immediate results (valve area ≥1.5 cm2 without regurgitation >2/4). Predictors of poor immediate results in multivariate analysis were older age (p < 0.001), lower initial valve area (p = 0.01) and the use of the double-balloon technique (p = 0.015). In the 175 patients who underwent follow-up, 8-year survival without operation and in New York Heart Association class I or II was 48 ± 5%, and 58 ± 6% after good immediate results. In this latter group, poor late functional results were predicted by higher cardiothoracic index (p < 0.0001), previous open-heart commissurotomy (p = 0.05) and lower final valve area (p < 0.0001) in a multivariate Cox model.CONCLUSIONSPercutaneous mitral commissurotomy is safe and provides good immediate results in selected patients with restenosis after surgical commissurotomy. After good immediate results, the conditions of more than half of the patients remained improved at 8 years, enabling reoperation to be deferred.

Ten-years clinical follow-up following successful percutaneous transvenous mitral commissurotomy: single-center experience.

The purpose of this study is to report the long-term follow-up outcome of patients undergoing percutaneous transvenous mitral commissurotomy (PTMC). The follow-up of 68 of 82 (83%) consecutive patients undergoing successful PTMC (mitral valve area of more than 1.5 cm(2) without major complications) in 1987 using the Inoue balloon was analyzed. The mean age at the time of PTMC was 52 +/- 11 years and 81% were female patients. The mean follow-up interval was 98 +/- 37 months (6 to 123). Actuarial survival rate was 98%, 97%, and 86% at 1, 5, and 10 years, respectively; the event-free (death, mitral valve replacement, and repeat PTMC) survival rate was 90%, 85%, and 66% at 1, 5, and 10 years, respectively. According to the echocardiographic findings, patients could be divided into three groups: pliable valve, semipliable valve, and rigid valve. Multivariable analysis identified echocardiographic subgrouping as the major significant predictor of any event: the event-free survival rate being 70% in group 1, 66% in group 2, and 20% in group 3 (P < 0.05). Echocardiographic follow-up was available in 49 of 68 patients (72%); the mitral valve area changed from 1.4 +/- 0.5 before to 2.1 +/- 0.4 immediately post-PTMC, and 1.8 +/- 0.4 cm(2) 10 years after the procedure. The long-term follow-up outcome following successful PTMC was favorable and seems to support it as a viable alternative to surgical commissurotomy in selected patients. Patients with rigid valves should be selected very carefully.