Symptomatic Rheumatic Mitral Stenosis Research Articles

Septal defects after percutaneous mitral valvotomy–all are not innocent

Percutaneous balloon mitral valvuloplasty (BMV) has become the procedure of choice for the treatment of symptomatic rheumatic mitral stenosis (MS). The defect produced in the atrial septum after transseptal puncture is an integral part of the valvotomy procedure.

Outcome of cases of Mitral Stenosis after Percutenuous Transvenous Mitral Commissurotomy (PTMC)

This prospective study was carried out in the National Institute of Cardiovascular Diseases and Hospital (NIC VD), Dhaka, Bangladesh during the period January 2002 to December 2002. The result of percutenuous ballon mitral valvotomy were evaluated in 153 cases of mitral stenosis patients (mean age 36±15 years) with symptomatic rheumatic mitral stenosis with single Inoue ballon technique PTMC results significant increase mitral valve area. 79.18 to 1.86 ±.37. Transmitral mean pressure gradient 19.6 ± 8.9 to 3.7±38, Decrease mean left atrial size 41.33±9.3 to 30.56±8.16 and Pulmonary artery systolic pressure 56±24 to 39 ±17, Peak pressure gradient (PPG) 19.6±8.9 to 8.7 ±3.8, But lower incidence of mitral regurgitation, only two cases developed MR grade Ill which were treated medically, one patient develop moderate haemopericardium which was treated conservatively. One patient was failed due to severe tight MS of valve area 0.5. No surgical intervention was needed.

Percutaneous transvenous mitral commissurotomy using an Inoue balloon in children with rheumatic mitral stenosis

Percutaneous transvenous mitral commissurotomy (PTMC) using the Inoue technique was performed in 557 patients with rheumatic mitral stenosis. Of these, 107 were children aged 10–18 years (mean±SD 14.5±2.3). All patients were symptomatic New York Heart Association (NYHA) Class II ( n=78) and Class III ( n=29). All were in sinus rhythm. Following PTMC, the mitral valve area (MVA) increased from 0.73±0.18 to 1.7±0.53 cm 2 ( P<0.001). There was a significant fall in mean transmitral gradient from 15.6±5.2 to 5.1±2.3 mmHg, and in mean pulmonary artery pressure from 41±15 to 28.4±10 ( P<0.001). Cardiac tamponade developed in one patient. One patient developed severe mitral regurgitation requiring emergency mitral valve replacement. Five patients (4.7%) developed moderate mitral regurgitation. There was no mortality or cerebral embolism in any of the children. Four patients (3.7%) had oximetry evidence of atrial septal defect. Mean mitral valve area and transmitral gradient at 14 months mean follow up was 1.68±0.4 cm 2 and 6±3.5 mmHg, respectively, and were comparable to the immediate post-PTMC results. Two patients (1.8%) developed restenosis. The immediate haemodynamic results in children were compared to 450 adult patients who underwent PTMC in the same period. The outcome was similar in both groups. Children were found to have significantly higher pulmonary artery pressure compared to adults. We found that PTMC using an Inoue balloon is very effective and safe in children, and consider that it should be the procedure of choice for young patients with symptomatic rheumatic mitral stenosis.

Mitral Balloon Valvuloplasty by Inoue Technique without Echocardiographic Standby

Mitral balloon valvuloplasty (MBV) by Inoue technique was performed in 85 patients with symptomatic rheumatic mitral stenosis (MS). Twenty-eight patients were male and 57 patients were female. The age range was nine to 59 years (mean 28). All patients were subjected to echocardiographic and Doppler examinations before and one day after the procedure. The first 57 patients were subjected to exercise tolerance tests (ETT) a few days before and a few days after the procedure. An echocardiographic score was measured regarding valve thickening, leaflet mobility, degree of calcification and the severity of involvement of subvalvular apparatus. The mitral valve area (MVA) increased from 0.9 +/- 0.2 cm2 to 1.9 +/- 0.45 cm2, (P<0.0001). The mitral gradient (MG) decreased from 20 +/- 5.8 mm/Hg to 5.05 +/-+ 3.2 mm/Hg (P<0.0001). Mean left atrial pressure (LAP) dropped from 25.85 +/- 8.4 mm/Hg to 11.05 +/- 5.4 mm/Hg (P<0.0001). Exercise tolerance test (ETT) increased from 5.59 +/- 1.3 to 11.75 +/- 1.48 min. (P<0.0001). Complications included severe mitral regurgitation (MR) in two patients (2.3%). In the first 57 patients, mild left-to-right shunt measured by green dye dilution technique had occurred in 40% of patients. In conclusion, MBV by Inoue balloon is a good alternative to surgical commissurotomy and echocardiographic standby is very helpful when it is available. However, MBV can be safely performed if echocardiography is inaccessible.

Results of percutaneous balloon mitral valvotomy in young adults

The results of percutaneous balloon mitral valvotomy (PBMV) were evaluated in 235 young patients (mean age 29 ± 11 years) with symptomatic rheumatic mitral stenosis, and the single-balloon Inoue technique was compared with the double-balloon Mansfield technique. PBMV was associated with a significant increase in Gorlin mitral valve area (0.78 ± 0.23 to 1.61 ± 0.64 cm 2; p < 0.001), and improvement in New York Heart Association functional class (2.78 ± 0.59 to 1.28 ± 0.58; p < 0.001). Mitral regurgitation increased significantly (0.4 ± 0.6 to 1.3 ± 1.0; p < 0.001), but was significant (≥3+) only in 19 patients (8%). Comparison of the Inoue and Mansfield techniques showed a significantly lower Gorlin mitral valve area after PBMV (1.55 ± 0.56 vs 1.74 ± 0.74 cm 2; p < 0.05), but a lower incidence of mitral regurgitation by color Doppler echocardiography (1.1 ± 0.7 vs 1.5 ± 0.8; p < 0.05) in the Inoue group. Patients were divided into those with nonpliable (valve score >8; group I) and pliable (score ≤ 8; group II) valves. Although significant increases in mitral valve area were obtained in both groups, mitral valve area by planimetry was significantly lower in group I (1.49 ± 0.46 vs 1.86 ± 0.44 cm 2; p < 0.05), whereas there was no difference in the amount of color Doppler mitral regurgitation (1.5 ± 1.0 vs 1.2 ± 0.7; p = NS). It is concluded that (1) in young patients with mitral stenosis, PBMV offers excellent palliation even in those with less ideally pliable valves; and (2) although the Inoue technique achieves smaller valve areas, it is accompanied by a lower incidence of mitral regurgitation.

Comparison of immediate hemodynamic response to closed mitral commissurotomy, single-balloon, and double-balloon mitral valvuloplasty in rheumatic mitral stenosis

The hemodynamic response to closed mitral commissurotomy, single-balloon, and double-balloon mitral valvuloplasty was compared using 20 patients in each group. All patients had symptomatic rheumatic mitral stenosis with a mitral valve area < 1 cm2, without any left atrial clot, mitral valve calcification, or mitral regurgitation. There was a significant improvement in hemodynamics following intervention in all three groups. The mean pulmonary artery pressure decreased from 49.1 +/- 17.5 to 28.6 +/- 8.3 mm Hg (p < 0.001), 48.8 +/- 12.3 to 34.0 +/- 13.9 mm Hg (p < 0.001), and 46.7 +/- 18.0 to 26.3 +/- 13.7 mm Hg (p < 0.001) in the closed mitral commissurotomy, single-balloon, and double-balloon mitral valvuloplasty groups, respectively. The mitral valve area increased from 0.62 +/- 0.27 to 1.5 +/- 0.5 cm2 (p < 0.001), 0.68 +/- 0.24 to 1.5 +/- 0.4 cm2 (p < 0.001), and 0.68 +/- 0.25 to 1.9 +/- 0.8 cm2 (p < 0.001) in the closed mitral commissurotomy, single-balloon, and double-balloon mitral valvuloplasty groups, respectively. The increase in the mitral valve area was maximum in the group with double-balloon mitral valvuloplasty. In the closed mitral commissurotomy group there was a significant rise in left ventricular end-diastolic pressure, from 6.8 +/- 3.9 to 9.3 +/- 3.1 mm Hg (p < 0.001), but this remained unchanged in the single-balloon and double-balloon mitral valvuloplasty groups. Our study shows that single-balloon and double-balloon mitral valvuloplasty are comparable to closed mitral commissurotomy in the immediate hemodynamic response, with a larger valve area in the double-balloon mitral valvuloplasty group.

Transesophageal Echocardiography During Percutaneous Balloon Mitral Valvuloplasty

To ascertain the value of transesophageal echocardiography during percutaneous balloon mitral valvuloplasty, the present study was undertaken in 26 anesthesized patients (21 women and 5 men; mean age, 47 years) with symptomatic rheumatic mitral valve stenosis. In all but one patient the balloon dilation of the mitral valve was successful and Doppler-derived valve area increased (0.9 +/- 0.3 to 1.9 +/- 0.4 cm2). Transesophageal echocardiography provides continuous monitoring, as well as guidance of the procedure. Crossing the arterial septum, as well as delivery of the sheath through the mitral valve orifice and correct positioning of the balloon, was highly facilitated and reduced x-ray exposure time. The degree of mitral regurgitation and the presence of interatrial shunting at the end of the procedure could be readily assessed, making cineangiography not necessary. Complications of the procedure, such as pericardial effusion, could be detected before hemodynamic deterioration had occurred (one patient). The advantages of transesophageal echocardiography for routine monitoring of percutaneous mitral valvuloplasty, however, should be weighted against the added risk and expense of this support.

Percutaneous mitral valvuloplasty with a single rubber-nylon balloon (Inoue balloon): Long-term results in 71 patients

The first 71 patients with rheumatic mitral stenosis who successfully underwent single rubber-nylon balloon (Inoue balloon) percutaneous mitral valvuloplasty (PMV) from November 1985 to August 1988 had a mean follow-up period of 27.1 ± 11.6 months (range, 14 to 48 months). Functional status before PMV was New York Heart Association (NYHA) functional class IV in two, class III in 38, and class II in 31. Pre and post PMV and follow-up mean diastolic mitral gradient by catheter method was 17.5 ± 6.9, 2.7 ± 3.5, and 3.3 ± 3.4 mm Hg ( p < 0.001 pre versus post PMV and pre PMV versus follow-up; and p > 0.05 post PMV versus follow-up). By Doppler method the mean diastolic gradient was 17.4 ± 5.5, 8.5 ± 4.7, and 9.2 ± 4.1 mm Hg, respectively ( p < 0.001 pre versus post PMV and pre PMV versus follow-up; and p > 0.05 post PMV versus follow-up). Mitral valve area was 1.12 ± 0.26, 2.04 ± 0.41, and 1.92 ± 0.45 cm 2, respectively ( p > 0.001 pre versus post PMV and pre PMV versus follow-up; and p > 0.05 post PMV versus follow-up). The phonocardiographic and vectorcardiographic studies and cardiopulmonary exercise testing showed significant improvement after PMV and at follow-up. At follow-up the NYHA functional class was I in 57 patients, class II in 13, and class III in one patient with severe mitral valve calcification and subvalvular fusion, in whom restenosis occurred 18 months after PMV. Thus single rubber-nylon balloon PMV can achieve very good short-term and long-term results in relieving symptomatic rheumatic mitral stenosis. Patients with severe mitral calcification and subvalvular fusion do not appear to be good candidates for PMV.

One-year follow-up after percutaneous double balloon mitral valvotomy

To determine the long-term results after double balloon mitral valvotomy and the incidence of restenosis, 41 consecutive patients were restudied 1 year after successful balloon mitral valvotomy for severe symptomatic rheumatic mitral stenosis. There were 27 female and 14 male patients, mean age 26 ± 9 years.