Underwent Balloon Mitral Valvotomy Research Articles

Gelatin sponge mimicking left atrial clot in rheumatic mitral stenosis

We report the case of a 23-year-old female who underwent balloon mitral valvotomy for severe symptomatic mitral stenosis. Following septal puncture, the patient developed cardiac tamponade, which warranted sternotomy to suture the rent in the inferior vena cava-right atrial junction. The postoperative echocardiogram revealed nonhomogenous irregular opacities within the left atrium suggesting the possibility of thrombus formation. As the patient was in sinus rhythm and peri-procedural activated clotting time was in therapeutic range, clot formation was unlikely. A review of operative notes revealed placement of absorbable hemostatic gelatin sponge within the pericardium, which was mimicking left atrial clot. This potential pitfall has to be recognized in echocardiograms, as it will avoid inappropriate anticoagulant therapy.

P-107 Assessment of Myocardial Contractility by Speckle-Tracking Imaging in Patients with Mitral Stenosis who Underwent Balloon Mitral Valvotomy

P-107 Assessment of Myocardial Contractility by Speckle-Tracking Imaging in Patients with Mitral Stenosis who Underwent Balloon Mitral Valvotomy

Comparison of Proximal Isovelocity Surface Area Method and Pressure Half Time Method for Evaluation of Mitral Valve Area in Patients Undergoing Balloon Mitral Valvotomy

The pressure half time (PHT) method is unreliable for measurement of mitral valve area (MVA) immediately after valvotomy. The proximal isovelocity surface area (PISA) method has been used to derive mitral valve area in patients with mitral stenosis. The aim of our study was to compare PISA method and PHT method in patients undergoing percutaneous balloon mitral valvotomy (BMV). The PISA was recorded from the apex and MVA was calculated using continuity equation by the formula 2pir(2) Vr/Vm, where 2pir(2) is the hemispheric isovelocity area, Vr is the velocity at the radial distance "r" from the orifice, and Vm is the peak velocity. A plain angle correction factor (theta)/180 was used to correct the inlet angle subtended by leaflet tunnel as a result of leaflet doming. MVA calculated using PISA method (r = 0.5217, P < 0.0001, SE = 0.016) and PHT (r = 0.6652, P < 0.0001, SE = 0.017) correlated well with 2D method in patients with mitral stenosis before BMV. After BMV, MVA by PISA method correlated well with 2D planimetry (r = 0.5803, P < 0.0001, SE = 0.053) but PHT showed poor correlation (r = 0.1334, P = 0.199, SE = 0.036). The variability of measurement of MVA was most marked with PHT method in the post-BMV period. The PISA method correlates well with 2D planimetry in patients with mitral stenosis before and after BMV and is superior to the PHT method in the post-BMV period where the latter may be unreliable.

Long-Term Outcome of Patients Undergoing Balloon Mitral Valvotomy in Pregnancy

The outcome of 36 patients (mean age 25.8 +/- 4.3 years) who underwent balloon mitral valvuloplasty during pregnancy is described in this report. The procedure was successful in 35 patients (97.2%), with no maternal mortality, and all patients subsequently had symptomatic improvement and uneventful deliveries. The children had normal growth and development at a follow up of 2.8 +/- 3.3 years. Thus, in patients with symptomatic severe mitral stenosis, balloon mitral valvuloplasty is feasible, safe, and effective with good long-term outcomes for both the mother and the fetus.

Mitral valve surgery and maternal and fetal outcome in valvular heart disease

Objectives: To compare maternal and fetal outcomes in patients with non-operated valvular heart disease and patients who had surgery before or during pregnancy. Methods: The 308 women with valvular heart disease who delivered in this hospital in the last 8 years were divided into three groups. The 218 (70.7%) women in group 1 had no surgical intervention; the 42 (13.6%) women in group 2 underwent balloon mitral valvotomy during pregnancy; and the 48 (15.5%) women in group 3 had surgical intervention before pregnancy (35 had balloon mitral valvotomy, eight had mitral valve replacement, and five had mitral valve repair). Maternal and fetal outcomes were compared for these three groups. Results: The antenatal events differed significantly: 175 (80.3%), 40 (94.2%), and 46 (95.8%) patients in groups 1, 2 and 3, respectively, had uneventful pregnancies. In group 1, 14 (6.4%) patients had congestive heart failure ( P>0.05) and 24 (11%) patients had cardiac arrhythmias, which was statistically significant. The rate of preterm deliveries did not differ significantly among the three groups. The groups did not differ in mean birth weight, mode of delivery, low birth weight, Apgar scores less than 8, stillbirths, neonatal death, or congenital anomalies. Conclusions: Mitral valve surgery before or during pregnancy did not significantly improve maternal and fetal outcomes but decreased adverse events such as congestive heart failure and cardiac arrhythmias. It should be therefore performed only in selected cases.

Inoue balloon mitral valvotomy in patients with atrial septal aneurysm

Atrial septal aneurysms (ASA) are not uncommonly detected in patients with rheumatic mitral stenosis and pose problems during transeptal puncture in patients undergoing balloon mitral valvotomy. From a period of August 1995 to May 1998, we performed a total of 680 Inoue Balloon Mitral Valvotomy (IBMV) procedures with ASA noted in 30 patients, 13 of diffuse and 17 localized type. Transesophageal echocardiography (TOE) was used in all patients with suspected aneurysm on transthoracic echo (TTE) for exact three-dimensional delineation of the location and extent of the aneurysm. The localized type of aneurysms were further subcategorized into five types viz. antero-superior and leftwards (6), postero-superior and rightwards (2), antero-inferior and leftwards (2), postero-inferior and rightwards (5), and central (2), depending on their location in the atrial septum. The site for transeptal puncture was decided after this localization and the remainder of the IBMV procedure was as usual. In the set of thirteen patients with diffuse type of atrial septal aneurysms all but one case had a successful transeptal puncture using standard technique except for a somewhat inferior puncture site so as to be perpendicular to the plane of atrial septum and a successful mitral valve dilatation was possible at first attempt. In the set of 17 patients with localized type of aneurysms, all had a successful transeptal puncture except one. In patients with aneurysms localized antero-superiorly and leftwards the septal puncture was done in a slightly inferior location with transeptal needle pointing some what more posterior, i.e. 5 or 6 o’clock position and in patients with aneurysms localized postero-inferiorly the puncture was done more cephalic with needle directed somewhat anterior, i.e. 3–2 o’clock position. In the two patients with Atrial septal aneurysms located postero-superiorly and to the right the puncture was done slightly inferior but with transeptal needle pointing to about 3 or 2 o’clock position and in the single patient with antero-inferior location the puncture was done in slightly higher but with a more posterior directed needle, i.e. 5–6 o’clock position. The two patients with centrally located localized type of aneurysms had successful transeptal puncture with standard needle direction (4 o’clock) but at a slightly inferior location. We conclude that a good localization of atrial septal aneurysms using transesophageal echocardiography and our technique of transeptal puncture leads to a successful outcome in majority of cases undergoing Inoue balloon mitral valvotomy with associated atrial septal aneurysms.

Percutaneous balloon mitral valvotomy in mitral restenosis.

Mitral restenosis often occurs within 5 to 15 years of surgical valvotomy. Percutaneous balloon mitral valvotomy is well established as a safe and effective alternative to mitral stenosis surgery, but only a few small studies have reported on the procedure. (i) To evaluate the safety and efficacy of percutaneous balloon mitral valvotomy in patients with mitral restenosis. (ii) To evaluate the intermediate-term outcome of patients undergoing balloon mitral valvotomy after previous surgical valvotomy. (iii) To compare these patients with those undergoing balloon mitral valvotomy as the initial procedure. We analysed our experience of 614 consecutive patients undergoing balloon valvotomy and identified 84 patients (13.7%) with mitral restenosis following prior surgical valvotomy (Group I). The remaining 530 patients (86.3%) had not undergone previous surgery (Group II). The incidence of atrial fibrillation (19% vs 5.6%), mitral valve calcification (50% vs 30.6%) and total echo score > 8 (54.8% vs 24.15%) was significantly higher in Group I. Both groups were comparable as regards their functional class, technique of valvotomy, mitral valve area (0.87 +/- 0.18 vs 0.87 +/- 0.15 cm2, P = ns), mean transmitral gradient (19.63 +/- 6.01 vs 19.21 +/- 5.67 mmHg, P = ns), and mean pulmonary artery pressure (42.2 +/- 19.0 vs 40.8 +/- 14.4 mmHg, P = ns). After percutaneous balloon mitral valvotomy, the final mitral valve area (1.67 +/- 0.28 vs 1.69 +/- 0.29 cm2, P = ns), mean transmitral-mitral gradient (6.12 +/- 3.68 vs 5.02 +/- 3.21 mmHg, P = ns) and mean pulmonary artery pressure (31.0 +/- 15.2 vs 28.5 +/- 11.1 mmHg, P = ns) were comparable. The success rate (93.0% vs 95.3%, P = ns) were similar in both groups. Significant mitral regurgitation was seen in four (4.8%) patients in Group I and 22 (4.1%) patients in Group II (P = ns). There were two deaths (2.4%) in Group I and five (0.9%) in Group II (P = ns). The clinical and echo Doppler follow-up (8-40 months) studies showed that both groups were of similar NYHA class, and had similar mitral valve area (1.65 +/- 0.21 vs 1.66 +/- 0.3 cm2) and transmitral gradients (7.1 +/- 3.8 vs 5.9 +/- 3.5 mmHg). We conclude that percutaneous balloon mitral valvotomy can be performed safely and effectively in patients with mitral restenosis following surgical valvotomy; the beneficial acute outcome is sustained, as shown at intermediate-term follow-up and is similar to that of patients undergoing balloon mitral valvotomy as an initial procedure.

Echocardiographic long-term evaluation of percutaneous balloon mitral valvotomy.

Percutaneous balloon mitral valvotomy (BMV) is an alternative therapeutic method for patients with mitral stenosis. We studied 62 patients (56 females, mean age 36.4 years) who underwent balloon mitral valvotomy. Five patients were pregnant and in New York Heart Association Functional Class IV. Doppler echocardiographic studies were performed prior to the procedure, and at 7 days, 6 months, 12 months, and 24 months after the procedure. We studied the following parameters: echo-score by the sum of valvular mobility, thickening, and calcification, and subvalvular disease, graded from 1 to 4; and mitral valve area (MVA) and mitral pressure gradient (MPG) by Doppler echocardiography. The patients were separated into two groups: group I with an echo-score less than or equal to 8 (40 patients), and group II with an echo-score greater than or equal to 9 (22 patients). Mitral valve area and MPG were compared with hemodynamics through the correlation coefficient and linear regression. Comparison between groups I and II was performed using the unpaired Student's t-test. Follow-up of MVA and MPG was analyzed by analysis of variance. The Student's t-test did not show any significant difference between MVA and MPG before balloon mitral valvotomy. There was significant decrease of MVA in group II (P less than 0.01) in the last three studies. There was significant increase in MPG in group II (P less than 0.01) in every postvalvotomy study. The analysis of variance of group I showed statistical increase of the MVA, and significant decrease of the MPG after BMV. The analysis of variance of group II showed significant increase in MVA and significant decrease in MPG between the pre- and the first postvalvotomy study. There was significant decrease (P less than 0.01) in MVA, and increase in MPG in the three postvalvotomy studies. Complications included mitral regurgitation, residual interatrial communication, pericardial effusion due to an atrial wall perforation, and peripheral embolization. Atrial fibrillation did not significantly alter the results of BMV. Results were considered positive when MVA was greater than 1.5 cm 2 and area increase was greater than 25%. Patients with an echo-score less than or equal to 8 (group I) benefit from BMV, with a positive predictive value greater than 78%. In pregnant patients the symptomatology was alleviated by BMV, without any signs of fetal compromise.

Effectiveness of percutaneous balloon mitral valvotomy during pregnancy

During pregnancy, medically refractory congestive heart failure due to mitral stenosis continues to present a clinical challenge and optimal management remains controversial. Thirteen women underwent balloon mitral valvotomy for control of functional class III or IV congestive heart failure due to mitral stenosis during pregnancy. The mean gestational age at the time of valvotomy was 25 ± 6 weeks. Percutaneous balloon mitral valvotomy was performed successfully in all patients. No maternal or fetal mortality occurred. The mean mitral valve area assessed by Doppler echocardiography increased from 0.9 ± 0.3 cm 2 before to 2.1 ± 0.3 cm 2 after valvotomy. The mean mitral valve gradient decreased from 20 ± 7 to 4 ± 2 mm Hg. This was associated with a decrease in the pulmonary artery systolic pressure from 62 ± 24 to 32 ± 14 mm Hg. Currently, 12 of the 13 patients have delivered at an average gestational age of 38 ± 0.5 weeks. Symptoms of congestive heart failure improved in all women and all were in New York Heart Association functional class I at the time of delivery. One patient is still pregnant and symptom free. Eleven singlet pregnancies resulted in the birth of full-term, healthy infants (mean birth weight 3.2 kg). The woman carrying a twin pregnancy improved from New York Heart Association class IV to class I after balloon mitral valvotomy but delivered prematurely at 32 weeks. The premature twin infants weighed 1.0 and 1.5 kg and died from respiratory failure at 48 hours. Percutaneous balloon mitral valvotomy can be performed safely during pregnancy and is effective in relieving symptoms of severe congestive heart failure. Balloon mitral valvotomy offers an effective alternative for the pregnant patient with severe mitral stenosis when congestive heart failure is not controlled by conventional medical treatment. The risk to the fetus appears lower than previous reports of surgical commissurotomy performed during pregnancy.