Underwent Balloon Mitral Valvotomy Research Articles

Predictive value of pre procedural mitral valve commissural score in in patients undergoing balloon mitral valvotomy.

Objective: To evaluate accuracy of commissural score in patients with mitral stenosis through Transesophageal Echocardiography (TOE) and correlate it with outcomes of BMV. Study Design: Prospective study. Setting: Chaudhry Pervez Elahi Institute of Cardiology, Multan. Period: June 2022 to November 2022. Material & Methods: Study was conducted on total 171 patients. Transesophageal echocardiography was performed before BMV by consultant cardiologist. The subvalvar apparatus and mitral valve leaflets were examined at transgastric and mid esophageal levels. Morphology of mitral valve was assessed on the basis of mitral valve commissural score. Graded ballooning was performed stepwise in increments of 1 to 2 mm for reducing the transmitral gradient to satisfactory level. If satisfactory hemodynamic result were not achieved even at maximum, process was stopped. Pre and post procedural echocardiographic measurements were recorded. Results: Mean age of the participants was 42.2±14.0 years. Mitral valve commissural score of ≥2 was noted in 151 (88.30%) patients. After BMV, good outcome was achieved in 150 (87.72%) patients, and in remaining 21 (12.28%) patients outcome was poor. The mitral valve commissural score had a PPV of 96.7% and NPV of 80.0%. Stratification was performed on the basis of age, gender, rheumatic heart disease, obesity and NYHA class. No association was found between these variable and mitral valve commissural score with good outcome. Conclusion: In patients undergoing BMV, high commissural score (3-4) is predictor of good outcome, while low commissural score is associated with unfavorable outcome.

Utility of cerebral oximetry in balloon mitral valvotomy and its correlation with post-procedure neurological complications: A pragmatic prospective observational study.

Neurological complications (NCs) are significantly associated with reduced regional cerebral saturation (rSO2) in patients undergoing cardiac surgeries, as assessed with cerebral oximetry (COx). However, limited evidence is available in patients undergoing balloon mitral valvotomy (BMV). Thus, we evaluated the utility of COx in patients undergoing BMV, the incidence of BMV-related NCs and the association of >20% reduction in rSO2 with NCs. This pragmatic, prospective, observational study was performed after ethical approval, over November 2018 to August 2020, in the cardiology catherization laboratory of a tertiary care hospital. The study involved 100 adult patients undergoing BMV for symptomatic mitral stenosis. The patients were evaluated at initial presentation, pre-BMV, post-BMV and 3 months after the BMV. The incidence of NCs was 7%, including transient ischaemic attack (n = 3), slurred speech (n = 2) and hemiparesis (n = 2). A significantly greater proportion of patients with NCs had a > 20% decrease in the rSO2 (P value = 0.020). At >20% cut-off, the COx had a sensitivity and specificity of 57.1% and 80%, respectively, in the prediction of NCs. Female sex (P value = 0.039), history of cerebrovascular episodes (P value < 0.001) and number of balloon attempts (P value < 0.001) were significantly associated with NCs. Patients with and without NCs had a significantly greater post-BMV mean % change in rSO2 than pre-BMV (both right and left sides), but the magnitude of mean % change was greater in those with NCs. COx alone has low sensitivity and specificity in the prediction of NCs and cannot reliably predict the development of post-BMV NCs.

Papillary muscle avulsion following balloon mitral valvotomy evaluated with three-dimensional echocardiography

BackgroundPercutaneous balloon mitral valvotomy is a common therapeutic approach for rheumatic mitral stenosis. Avulsion of the papillary muscle is a rare but serious complication of balloon mitral valvotomy. The papillary muscles are derived from the trabecular layer of the developing ventricular walls. When subjected to a force, avulsion of papillary muscle from the trabecular layer may occur.Case presentationIn this case report, we describe a patient with rheumatic mitral stenosis, who experienced avulsion of the mitral papillary muscle from the left ventricular wall after undergoing balloon mitral valvotomy. Papillary muscle alvusion resulted in severe mitral regurgitation, which was finally treated by mitral valve replacement.ConclusionWe successfully diagnosed avulsion of the papillary muscle following balloon mitral valvotomy. Three-dimensional transthoracic echocardiography provides more information on mitral apparatus structure than two-dimensional transthoracic echocardiography.

Balloon Mitral Valvotomy With the Accura Double-Lumen Balloon Catheter: Immediate and One-Year Clinical Outcomes.

ObjectiveDespite the decline in the incidence of rheumatic heart disease in developed countries, the disease still remains endemic among individuals of low socioeconomic status. The aim of the study is to assess immediate and one-year outcomes of balloon mitral valvotomy using the double-lumen Accura balloon (Vascular Innovations Co., Nonthaburi, Thailand) in patients with mitral valve stenosis.MethodsThis was a single-centre, observational, investigator-initiated retrospective study. All consecutive patients undergoing balloon mitral valvotomy with the Accura balloon between January 2015 and June 2020 were included. The primary endpoint was procedural success defined as an increase in mitral valve area (MVA) ≥50% from basal valve area or final valve area of ≥1.5 cm2, in the absence of mitral regurgitation grade >2. Clinical, echocardiographic, and haemodynamic parameters were assessed at the one-year follow-up.ResultsA total of 62 patients underwent balloon mitral valvotomy. The mean age was 34.9 ± 8.0 years, and 54 (87.1%) patients were female. Mean Wilkins' echo score was 7.5 ± 0.5. Procedural success was achieved in 59 (96.7%) patients. Mean MVA increased from 0.75 ± 0.14 cm2 to 1.64 ± 0.21 cm2, and mean mitral valve gradient decreased from 24.9 ± 5.5 mmHg to 7.30 ± 1.40 mmHg. Atrial fibrillation, mitral valve replacement, and moderate to severe mitral regurgitation occurred in 36 (59.0%), two (3.3%), and two (3.3%) patients, respectively. No death, cerebrovascular accidents, restenosis, or redo procedures occurred.ConclusionBalloon mitral valvotomy using the double-lumen Accura balloon is safe in patients with mitral valve stenosis.

Is left atrial fibrosis an independent determinant of atrial fibrillation in mitral stenosis?

We prospectively studied whether left atrial (LA) fibrosis is a determinant of atrial fibrillation (AF) in mitral stenosis in patients who underwent balloon mitral valvotomy. There were 2 groups: Group A (n = 16), with AF and Group B (n = 27), without AF. Fibrosis was assessed by MRI. Patients underwent cardioversion before MRI. There were 27 females and 16 males, aged 29 ± 6 years. The LA areas in Groups A and B were 54.3 ± 4.4 mm2 and 39.4 ± 2.3 mm2 (p < 0.05) and the LA volume index was 46.2 ± 2.9 ml/m2 vs 33 ± 3 ml/m2 respectively (p < 0.0001). The presence of LA scarring was not statistically different in the two groups.

Maternal and fetal outcomes in pregnant females with rheumatic heart disease

BackgroundCardiac diseases are seen in 1–3% of pregnancies. In developing countries rheumatic heart disease (RHD) contributes a major cause of cardiac disorders. ObjectiveTo study the maternal and fetal outcome in women with valvular heart disease or prosthetic heart valve replacement secondary to RHD in a tertiary care center. MethodThe consecutive pregnant women with RHD attending our institute from May 2018 to August 2019 were included. A maternal adverse outcome was defined as cardiac death, new onset arrhythmia, heart failure, thromboembolic event, hospitalization for other cardiac reasons or cardiac intervention, aortic dissection, infective endocarditis and acute coronary syndrome. Fetal adverse outcome defined as fetal death, preterm birth, and low birth weight. ResultTotal 80 patients were included in this study, native RHD in 60(75%) and 20(25%) had mechanical prosthetic valve replacement. Maternal adverse event occurred in 34(42.5%), comprising of death in 1(1.2%), new onset AF 2(2.5%), 20(25%) underwent balloon mitral valvotomy, 3(3.7%) underwent mitral valve replacement, heart failure hospitalization in 7(8.7%). 1(1.2%) patient developed mitral valve infective endocarditis. Preterm delivery occurred in 19(23.7%), 7(8.7%) abortions and 1(1.2%) intrauterine death. Fetuses with low birth weight were 43(53.7%). Pregnancy with live birth occurred in 57(95%) women with valvular heart disease but no prosthesis and 16(80%) women with prosthetic valve disease. ConclusionWomen with rheumatic heart disease carry a high risk both for mother and fetus. Early diagnosis, close follow-up during pregnancy, early recognition of deterioration in symptoms and timely cardiac intervention can lead to good maternal or fetal outcome.

Immediate, early and mid-term outcomes following balloon mitral valvotomy in patients having severe rheumatic mitral stenosis with significant tricuspid regurgitation.

The study examined the influence of significant tricuspid regurgitation (TR) on the immediate, early and mid-term outcomes of patients with severe mitral stenosis (MS) undergoing balloon mitral valvotomy (BMV). Among the 818 consecutive patients who underwent elective BMV in this institute from 1997 to 2003, 114 had significant TR. After propensity score-matched analysis, the data of 93 patients with significant TR were compared with the data of 93 patients who had no significant TR at the baseline. Outcomes were assessed immediately, at 1year (early) and at 5years (mid-term) after BMV. Patients with significant TR presented more frequently with NYHA class III-IV status, atrial fibrillation (AF), severe pulmonary hypertension (PH), advanced mitral valve disease as assessed by echocardiographic score >8, and with history of previous BMV. After propensity score-matched analysis, it was found that the immediate procedural success (54.8% vs. 58.1%, P = 0.650), immediate in-hospital events and prevalence of AF and heart failure at 1year of follow-up were comparable between the two groups. At 5years after BMV, the significant TR group had higher prevalence of heart failure and AF, greater attrition in mitral valve area (MVA) and higher pulmonary artery (PA) pressure. Significant TR identifies a sicker patient population with MS. Even though patients with significant TR have comparable immediate and early outcomes after BMV, they have poor outcomes on mid-term follow-up. Longer follow-up with more patients is needed to assess survival aspect of TR on patients undergoing BMV and also to look at the need for interventions to address the significant TR, apart from the mitral valve interventions.

Immediate and long-term outcomes of balloon mitral valvotomy in pregnancy

ObjectivesTo study the immediate maternal and fetal outcomes and long term maternal outcomes in pregnant women undergoing balloon mitral valvotomy. MethodsWe retrospectively analyzed balloon mitral valvotomy during pregnancy performed between January 2008 and July 2018. ResultsBMV was carried out in 97 pregnant women with mean age of 26.1 ± 4.5 years, at mean gestational age of 23.1 ± 4.6 weeks. The procedure was successful in 95 patients (97.9%). There was one maternal death post procedure due to intra-uterine death and disseminated intravascular coagulation. Adverse immediate fetal outcome was seen in 2 cases with one intra-uterine fetal demise and one preterm labour. Mitral valve area increased from mean of 0.82 ± 0.12 cm to 1.66 ± 0.14 cm (p < 0.001). Mean trans-mitral diastolic gradient decreased from 19.7 ± 5.6 mm Hg to 7.5 ± 2 mm Hg. Right ventricular systolic pressure decreased significantly from mean of 56.7 ± 16.2 mm Hg to mean of 35.6 ± 11 mm Hg. Survival analysis showed cumulative event free survival of 89% at 5 years and 65% at 10 years, considering a composite endpoint of clinical restenosis, repeat BMV or MVR or cardiovascular death. ConclusionsBalloon mitral valvotomy is a safe and effective treatment for severe mitral stenosis during pregnancy. Long term maternal outcomes after BMV done during pregnancy are good and comparable to that of BMV done in non-pregnant patients.

Left atrium function testing in pre- and post-balloon mitral valvotomy patients using 2d speckle tracking of strain imaging.

Background: Rheumatic Mitral stenosis is a concern in developing world. Quantification of the left atrium (LA) strain by bi-dimensional speckle tracking echocardiography is a new diagnostic technique. Objectives: To assess the left atrium function by Two-Dimensional Speckle-tracking echocardiography in patients with moderate to severe mitral stenosis (MS), among the patients undergoing balloon mitral valvotomy (BMV) procedure. Methodology: Echocardiography examination was conducted among 37 patients with rheumatic MS, before and after 24 hours of BMV were included. Functional assessment of LA was done by the assessment of MS by planimetry method, mean pressure gradient and two-dimensional speckle tracking echocardiography (STE). Distribution of mitral valve area (MVA), myocardial perfusion grade (MVG), LA volume, STE 4C and STE 2C were assessed before and after treatment. Comparison of variables between pre-test and post-test of mean pressure gradient (MPG), STE 4C, STE 2C and global longitudinal strain (GLS) was done using Student’s “t” test and comparison of MVA and LA volume was carried out using Wilcoxon signed rank test with p-value<0.05 considered as significant. Results: Mitral valve area increased to 1.7+0.11 cm2 post- BMV with a statistical significance of p<0.0001. LA volume showed a marked reduction after BMV i.e. 51.34 ± 20.14 sq.cm. There was a significant improvement in the LA strain i.e. STE 4C, STE 2C and GLA; with p<0.001. Conclusion: A marked improvement of the LA function among the patients with symptomatic mitral stenosis was observed, which was an indicator of successful BMV, with the aid of STE.

Strain imaging to assess early effects of successful percutaneous balloon mitral valvotomy on left atrium mechanics

BackgroundGlobal left atrial strain (LA) has been used as a novel assessment tool to evaluate left atrial function. However, not much has been investigated to study the effect of percutaneous balloon mitral valvotomy (BMV) in patients with rheumatic severe mitral stenosis on global LA strain. We studied the relationship between global left atrial (LA) strain and severe mitral stenosis and the effect of BMV on LA strain.ResultsA total of 29 patients satisfying the criteria for severe mitral stenosis underwent balloon mitral valvotomy (67% females; mean age, 39.53 ± 11.78 years). Global left atrial strain was assessed by speckle tracking echocardiography before and after valvuloplasty. Global LA strain was impaired in patients with severe mitral stenosis and improved 24–48 h following BMV (13.4 ± .75% vs 17.37 ± 6.95%, p < 0.001). There was a significant decrease in mitral mean gradient (MMG) (16.94 ± 6.62 mmHg vs 8.19 ± 4.01 mmHg, p < 0.001) and systolic pulmonary artery pressure (sPAP) (47.84 ± 9.07 mmHg vs 36.88 ± 7.69 mmHg, p < 0.001) after BMV. Mitral valve area (MVA) (1.045 ± 0.17 cm2 vs 1.94 ± 0.22 cm2, p < 0.001) significantly increased after BMV. Results were compared with 30 age- and sex-matched healthy controls.ConclusionGlobal LA strain can be taken as an indicator of left atrial function, and its improvement following valvotomy may be taken as a good indicator of successful BMV.

Factors affecting the outcome of pregnancy with rheumatic heart disease: an experience from low-middle income country

Studies on pregnancy with rheumatic heart disease (RHD), still common in the developing world, are relatively old and small. This retrospective study was conducted to study the outcome of pregnancy in women with RHD and factors associated with poor outcome. We studied 353 pregnancies in 273 women. In 35% of the patients, the diagnosis was first made during index pregnancy. Women with severe MS had lesser gestational age at delivery and birth weight than those with mild-to-moderate MS. Women with NYHA III-IV status delivered at lesser gestational age had lesser birth weight and had higher perinatal and maternal mortality than NYHA I-II status. Pregnancy outcome was better among women who underwent Balloon mitral valvotomy (BMV) when indicated than those who did not. Cardiac complications were higher in women with severe MS and poor NYHA status. Early booking is important for the optimal outcome. BMV is safe during pregnancy and should be done when necessary.Impact statementWhat is already known on this subject? Rheumatic heart disease continues to be the major cause of maternal morbidity and mortality in developing countries. Most of the recent studies discuss pregnancy with heart disease as a whole with RHD being a part.What do the results of this study add? A large number of women in developing countries conceive with unknown underlying heart disease. Late access to antenatal care is associated with poor outcome. Cardiac and obstetric complications are significantly higher in women with severe mitral stenosis and poor NYHA functional status. Balloon mitral valvotomy (BMV) during pregnancy is safe and technically feasible. BMV averts major complications that may occur due to severe disease. Patients with RHD can undergo labour and vaginal delivery under vigilant monitoring.What are the implications for clinical practice? Thorough clinical examination by the clinician at initial visit is important to detect unknown heart disease. Symptoms pointing towards underlying heart disease should prompt evaluation. This study provides evidence for population-based screening for heart disease in women. Optimal management of compensated mitral stenosis requires weighing the risks and benefits of pharmacological therapy versus BMV in the context of maternal condition. BMV should be performed when necessary.

Conscious sedation for balloon mitral valvuloplasty

Introduction: Analgesia and sedation are required for the comfort of patient and the cardiologist during Balloon mitral valvotomy. Efficacy of analgesia, sedation, and patient satisfaction with conscious sedation and local anesthesia was compared with local anaesthesia only during procedure. &#x0D; Methods: This was single-centered, pro­spective study conducted in Chitwan Medical College. All 66 patients, who underwent Balloon mitral valvotomy from February 2015 to January 2017, were enrolled in this study. They were divided into two groups by com­puter generated randomization. Thirty three patients received bolus injection fentanyl 1 mcg/kg and injection midazolam bolus 0.02 mg/kg along with local anaesthesia (20ml xylocaine) at femoral puncture site and other 33 patients received local anaesthesia only. Pain intensity (by visual analog score), anxiety score, overall patient and operator’s satisfaction, and effect on cardio respiratory parameters were assessed. Student’s unpaired t-test was applied. P &lt; 0.05 was considered statistically significant. &#x0D; Results: Both the groups were comparable with respect to age, gender and pre and post balloon mitral valvotomy mitral valve area. Statistically significant difference was found with respect to anxiety score (1.1 + 0.43 Vs. 1.99 + 0.01), VAS score (operator’s opinion) (9.10 + 0.56 Vs. 7.53 + 1.01) and VAS score (patient’s opinion) (8.54 + 0.87 Vs. 5.55 + 1.14). Fall in systolic pres­sure, diastolic blood pressure, mean arterial blood pressure, and respiratory rate was found in fentanyl group, but the values were within normal limits and statistically not significant. &#x0D; Conclusion: Conscious sedation with bolus dose of fentanyl and midazolam with local anesthesia at puncture site is better than only local anesthesia during balloon mitral valvotomy procedure to relieve patient’s anxiety and to improve patient’s and operator’s comfort without affecting hemodynamic parameters.

Comparative study on maternal and fetal outcome in pregnant women with rheumatic heart disease and severe mitral stenosis undergoing percutaneous balloon mitral valvotomy before or during pregnancy

IntroductionMitral stenosis due to rheumatic heart disease is a common problem in India causing significant morbidity and mortality. We have compared the maternal and fetal outcome of women with severe mitral stenosis undergoing percutaneous balloon mitral valvotomy before or during pregnancy. MethodsA total of 24 women of severe rheumatic mitral stenosis who underwent balloon mitral valvotomy before pregnancy (14 women, group 1) or during pregnancy (10 women, group 2) were included in the retrospective descriptive analysis. ResultsThe mean age was 25.5±3.6 yrs in group 1 and 25.7±3.5 yrs in group 2. There was no difference in characteristics –primigravidas, time since diagnosis from pregnancy, NYHA (New York Heart Association) class and associated medical problems in the two groups. There was significant difference in cardiac events during pregnancy in the two groups. New York Heart Association class deterioration was observed in only 3(21.4% women in group 1) as compared to all (10; 100% women) in group 2(p<0.001). The incidence of arrhythmias and atrial fibrillation was not different in two groups. Obstetric events were similar in the two groups. Mode of delivery and caesarean section rate was also similar in the two groups. There was no significant difference in mean birth weights (2399.75±601.8gm vs. 2641.70±580.6gm),rate of fetal growth restriction, still birth and congenital malformation rates in the two groups. ConclusionPercutaneous mitral valvotomy for patients with severe mitral stenosis can be safely performed during pregnancy and has equivalent maternal and fetal outcomes as that performed before pregnancy.

Maternal and fetal outcomes in pregnant women undergoing balloon mitral valvotomy for rheumatic mitral stenosis

BackgroundRheumatic mitral stenosis constitutes a major cause of acquired heart disease complicating pregnancy in India. In the present study, we have studied the fetal and maternal outcomes of women undergoing balloon mitral valvotomy during pregnancy. Methods and results49 pregnant ladies were included in this study in whom balloon mitral valvotomy was performed. The mean age of these patients was 25.7±3.1 years. The mean gestational age was 23.5±5.2 weeks (12–36 weeks). The procedure was successful in 48 patients (95.9%). Mean two-dimensional MVA increased from baseline value of 0.93±0.17cm2 to 1.75±0.27cm2 (p value <0.0001). Pre-procedure peak pulmonary artery pressure was 43.05±15.88mmHg, which decreased to 22.31±6.36mmHg (p value <0.0001). Hemodynamic data showed pre-BMV left atrial mean pressure of 29.6±6.6mmHg, which decreased to 13.7±4.8mmHg after the procedure (p value <0.0001). Mean fluoroscopy time was 6.4±1.2min. There was no maternal mortality in our study. One procedure had to be abandoned, because of failed septal puncture. One of the patients developed cardiac tamponade and another patient developed severe mitral regurgitation, which were managed medically. The patient who developed severe mitral regurgitation later underwent mitral valve replacement. Post-procedure follow-up showed an improvement in NYHA status by at least one class in 81.3% of patients. Thirty-nine (81.3%) patients had a term normal vaginal delivery and 8 (16.7%) underwent cesarean section for obstetric indications. One of the patients had abortion on the second day of the procedure. ConclusionPercutaneous mitral valvotomy during pregnancy is safe and provides excellent symptomatic relief and hemodynamic improvement. This should be considered as the treatment of choice when managing pregnant women with severe mitral stenosis.

Effect of balloon mitral valvotomy on left ventricular function in rheumatic mitral stenosis

AimMitral stenosis (MS) is found to produce left ventricular (LV) dysfunction in some studies. We sought to study the left ventricular function in patients with rheumatic MS undergoing balloon mitral valvotomy (BMV). Ours is the first study to analyze effect of BMV on mitral annular plane systolic excursion (MAPSE), and to quantify prevalence of longitudinal left ventricular dysfunction in rheumatic MS. MethodsIn this prospective cohort study, we included 43 patients with severe rheumatic mitral stenosis undergoing BMV. They were compared to twenty controls whose distribution of age and gender were similar to that of patients. The parameters compared were LV ejection fraction (EF) by modified Simpson's method, mitral annular systolic velocity (MASV), MAPSE, mitral annular early diastolic velocity (E′), and myocardial performance index (MPI). These parameters were reassessed immediately following BMV and after 3 months of procedure. ResultsMASV, MAPSE, E′, and EF were significantly lower and MPI was higher in mitral stenosis group compared to controls. Impaired longitudinal LV function was present in 77% of study group. MAPSE and EF did not show significant change after BMV while MPI, MASV, and E′ improved significantly. MASV and E′ showed improvement immediately after BMV, while MPI decreased only at 3 months follow-up. ConclusionsThere were significantly lower mitral annular motion parameters including MAPSE in patients with rheumatic mitral stenosis. Those with atrial fibrillation had higher MPI. Immediately after BMV, there was improvement in LV long axis function with a gradual improvement in global LV function. There was no significant change of MAPSE after BMV.

All Breathlessness in Mitral Stenosis is Not Pulmonary Edema- A Case of Mitral Stenosis with Cardio Respiratory Arrest

Anaphylactic shock in periprocedural period poses diagnostic and therapeutic challenge. Here we report a case of severe mitral stenosis developed sudden cardio respiratory arrest after parenteral antibiotic injection while being prepared for elective balloon mitral valvotomy. After initial resuscitation patient was taken up for emergency balloon mitral valvotomy in view of referactory shock. Patient developed air embolism during the procedure in view of reduced right atrial pressure which was successfully managed. She underwent balloon mitral valvotomy. Patient developed renal failure and deranged haematological parameters which were managed accordingly, finally the patient made a complete recovery. Key words: Anaphylactic shock, Air embolism, Balloon mitral valvotomy.

Balloon Mitral Valvotomy in Juvenile Rheumatic Mitral Stenosis: Comparison of Immediate Results with Adults

The objective of the study was to study and compare the clinical, echocardiographic and haemodynamic profile of juvenile rheumatic mitral stenosis (age ≤20 years) with severe mitral stenosis in adults, both before and immediately after balloon mitral valvotomy and also to evaluate the safety and efficacy of the procedure in juvenile patients. Forty juvenile patients aged 20 years or younger were analysed with 40 consecutive adult patients who underwent balloon mitral valvotomy using Accura balloon in our institution. The procedure was successful in all the patients. The clinical, echocardiographic and haemodynamic parameters were compared pre- and post-balloon mitral valvotomy in both the groups. New York Heart Association functional class was comparable in both the groups (II and III, 62.5% and 37.5% vs. 60% and 40%). Atrial fibrillation was not seen in the juvenile group whereas 25% of the adult group had atrial fibrillation (p<0.001). Mitral valve deformity was comparable (Wilkins Score - 8.57±0.67 vs. 8.6±0.67, p=NS). Mitral valve area index by 2D echo was 0.62±0.097 cm2/m2 in the juvenile group and 0.621±0.097 cm2/m2 in the adult group (p=0.72) and was larger in the juvenile group (1.38±0.19 vs 1.29±0.18 cm2/m2) after the procedure (p value <0.03). Mitral valve gradient (19.85±7.31 mm hg vs. 14.63±5.33 mm hg. P value<0.001) and mean PASP (70.15±1+.2 mm hg vs. 60.10±19.32 mm of hg. P value <0.02) was higher in the juvenile group before balloon mitral valvotomy, after balloon mitral valvotomy the values were 7.45±2.57 vs. 5.78±2.24 mm of hg, (P<0.003) and 40.48±10.30 vs. 41±15.62 respectively (p=0.85). The mean value for left atrial pressure was comparable in both the groups both pre- and post-balloon mitral valvotomy (P value 0.076 and 0.54 respectively). There was no significant difference in the procedural success (95% vs 100%, p value <0.15). Balloon mitral valvotomy is safe and effective in young with rheumatic mitral stenosis and provides better immediate results compared to adults.

Transcatheter therapy for Lutembacher′s syndrome: The road less travelled

An 18-year-old male with Lutembacher's syndrome underwent balloon mitral valvotomy (BMV) and device closure of the atrial septal defect (ASD). BMV necessitated technical modification of taking the Inoue balloon over the wire (OTW) into the left ventricle (LV). The procedure was complicated by slippage of ASD device into the right atrium, which was managed successfully by percutaneous retrieval, and deployment of a larger device. The case highlights the challenges associated with the seemingly easy transcatheter therapy for this disease entity.

Persistent Pulmonary Artery Hypertension in Patients Undergoing Balloon Mitral Valvotomy

Pulmonary artery pressure (PAP) is known to regress after successful balloon mitral valvotomy (BMV). Data of persistent pulmonary artery hypertension (PPAH) following BMV is scarce. We analyzed the clinical, echocardiographic, and hemodynamic data of 701 consecutive patients who have undergone successful BMV in our institute from 1997 to 2003. Data of 287 patients who had PPAH (defined by pulmonary artery systolic pressure [PASP] of ≥ 40 mmHg at one year following BMV) were compared to the data of 414 patients who did not have PPAH. Patients who had PPAH were older (39.9 ± 9.9 years vs. 29.4 ± 10.1; P < 0.001). They had higher prevalence of atrial fibrillation (AF; 21.9 vs. 12.1%, P < 0.05), moderate or severe pulmonary artery hypertension (PAH) defined as PASP more than 50 mmHg (43.5 vs. 33.8%, P = 0.00), anatomically advanced mitral valve disease as assessed by Wilkin's echocardiographic score > 8 (33.7 vs. 23.2%, P < 0.001), and coexistent aortic valve disease (45.6 vs. 37.9%, P < 0.001) at the baseline. Those patients with PPAH had comparatively lower immediate postprocedural mitral valve area (MVA). On follow-up of more than five years, the occurrence of restenosis (39.3 vs. 10.1%, P = 0.000), new onset heart failure (14% vs. 4%, P < 0.05) and need for reinterventions (9.5% vs. 2.8%, P < 0.05) were higher in the PPAH group. Patients with PPAH were older, sicker, and had advanced rheumatic mitral valve disease. They had higher incidence of restenosis, new onset heart failure, and need for reinterventions on long term follow-up. PPAH represents an advanced stage of rheumatic valve disease and indicates chronicity of the disease, which may be the reason for the poorer prognosis of these patients. Patients with PPAH requires intense and more frequent follow-up.

Immediate and Long‐term Results Following Balloon Mitral Valvotomy in Patients With Atrial Fibrillation

The purpose of this study was to examine the influence of atrial fibrillation (AF) on the immediate and long-term outcome of patients undergoing balloon mitral valvotomy (BMV). Patients with atrial fibrillation fair poorly after balloon mitral valvotomy. There were a total of 818 consecutive patients who underwent elective BMV in this institute from 1997 to 2003, with either double-lumen or triple-lumen BMV catheters included in the study. Of them, 95 were with AF. The clinical, echocardiographic, and hemodynamic data of these patients were compared with those of 723 patients in normal sinus rhythm (NSR). Immediate procedural results and long-term events were compared between the 2 study groups. Patients with AF were older (39.9 ± 9.9 years vs 29.4 ± 10.1, P < 0.001) and presented more frequently with New York Heart Association (NYHA) class III-IV (53.7% vs 32.9%, P < 0.001), echocardiographic score >8 (47.4% vs 24.9%, P < 0.001), and with history of previous surgical commissurotomy (33.7% vs 11.5%, P < 0.001). In patients with AF, BMV resulted in inferior immediate and long-term outcomes, as reflected in a lesser post-BMV mitral valve area (1.3 ± 0.4 vs 1.6 ± 0.4 cm(2), P = 0.032) and higher event rate on follow-up. Patients with AF were older, sicker, and had advanced rheumatic mitral valve disease. They had a higher incidence of stroke, new onset heart failure, and need for reinterventions on long-term follow-up. These patients need intense and more frequent follow-up.