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Background: The purpose of this study is to identify independent echocardiographic predictors of mitral stenosis (MS)-related death or intervention in infants. Congenital MS is a rare and morphologically heterogeneous lesion with variable prognosis. Among patients diagnosed with MS in early infancy, echocardiographic factors associated with MS-related intervention or death have not been determined., Methods and Results: The clinical and echocardiographic data of patients diagnosed with MS at age <6 months by echocardiography between 1986 and 2004 were reviewed. The primary outcome was a composite end point of either mitral valve (MV) intervention (catheter or surgery) or death related to MS. Multiple variables from the initial echocardiogram were analyzed for association with outcomes. Seventy-one patients (median age at diagnosis 63 days) fulfilled the inclusion criteria. Multivariate analysis identified higher initial MV mean inflow gradient (P = .009) and lower left ventricular (LV) diastolic length Z-score (P = .006) at presentation as predictors of intervention or death. Among patients with an initial MV inflow gradient < 2 mm Hg, none reached an end point, whereas, among patients with an initial mean gradient >/= 5.5 mm Hg, the risk of intervention or death was 85%. Among patients with a gradient > 2 and < 5.5 mm Hg, an end point was reached in 38%, and an LV diastolic length Z-score

We examined the immediate results and 2-year follow-up of percutaneous transvenous mitral commissurotomy (PTMC) using the Inoue balloon (IB) and double-balloon (DB) techniques. Short-term comparisons have been described, but long-term comparisons have not been available. PTMC was performed in 208 adult patients with symptomatic mitral stenosis (MS) and mitral valve area (MVA) of 0.94 +/- 0.2 cm2, by use of the IB in 157 (73.4%) and the DB technique in 56 (26.3%). Procedures were performed successfully and without complications in 198 (93%) cases. Adequate mitral dilatation (MVA = 1.6 cm2) without significant regurgitation was obtained in 179 (86%) of 192 patients. The final MVA was 2.0 +/- 0.43 cm2 after IB and 2.06 +/- 0.51 cm2 after DB (not significant). Technical difficulties and complications were more frequent with DB (16% vs 3.8%; p<0.001). Severe mitral regurgitation (grade III to IV) occurred in 4.6% of IB and 4.1% of DB (not significant), whereas grade 1 mitral regurgitation was greater with IB (21% vs 10.2%; p=0.01). A total of 172 patients were monitored an average of 23.8 +/- 10.6 months, with 83% in New York Heart Association functional class 1, echocardiographic MVA of 1.84 +/- 0.44 cm2, and restenosis rate of 22% at 36 months. PTMC is a safe, effective treatment for symptomatic MS. Results of both IB and DB techniques are similar, but the IB is simpler and safer, Long-term clinical improvement is maintained, although the restenosis rate seems to be progressive and related to inadequate immediate results.

Left atrial spontaneous echocardiographic contrast (SEC) is an important marker of increased thromboembolic risk in patients with mitral stenosis. To evaluate the effect of percutaneous transseptal mitral valvuloplasty (PTMV) on SEC, we performed transesophageal echocardiography 1 day before and 3 months after PTMV on 88 consecutive patients. SEC was present in 65 (74%) patients before PTMV and was associated with absence of moderate or severe mitral regurgitation (p = 0.01), a smaller valve area (p = 0.02), an older age (p = 0.04), and atrial fibrillation (p = 0.05). At 3 months, PTMV resulted in a mean absolute and relative increase in valve area of 0.54 +/- 0.36 cm2 and 53% +/- 43%, respectively. SEC resolved in 37 patients but persisted in 28 (32%) patients at the 3-month study. The absolute and relative increase of valve area and worsened mitral regurgitation after PTMV were predictors of resolution of SEC, with the relative increase in valve area being the only significant predictor on multivariate analysis. PTMV frequently results in resolution of SEC, which may have important implications in reducing the thromboembolic risk in these patients.

In 136 consecutive patients who underwent percutaneous transvenous mitral commissurotomy (PTMC) with use of the single rubber-nylon (Inoue) balloon Inoue balloon angiographically analyzed subvalvular fibrosis was assessed retrospectively with regard to results and complications. There were 53 males and 83 females, with a mean age of 22 +/- 11 years (range 10 to 48 years). For the entire group, mitral valve area increased from 0.7 +/- 0.3 to 2.1 +/- 0.6 cm2 (p < 0.001). Valve area increased from 0.7 +/- 0.12 to 1.8 +/- 0.14 cm2 in patients with severe subvalvular fibrosis (n = 55) and from 0.8 +/- 0.11 to 1.9 +/- 0.12 cm2 in cases with mild to moderate subvalvular fibrosis (n = 80; p = NS). The number of patients with 2+ or greater increase in mitral regurgitation was not different between the two groups (6% vs 5.5%, p = NS). None of the patients required mitral valve replacement immediately after PTMC. We conclude that, with use of the Inoue balloon, PTMC can be successfully performed in patients with severe subvalvular fibrosis.

Percutaneous mitral balloon valvotomy (PMV) using the Inoue balloon technique was attempted in 170 patients. Of these, 30 patients were children aged 10 to 18 years (mean 15.9 +/- 2.7 years). There were 16 female and 14 male patients. All were in sinus rhythm. The procedure was successful in 28 patients (93%). PMV was performed using 20 to 28 mm (mean 25 mm) diameter balloon catheters with an echo-Doppler guided stepwise mitral dilation technique. After PMV, the mean left atrial pressure decreased from 25 +/- 5 to 14 +/- 4 mm Hg (p < 0.001). The mean mitral valve gradient (MVG) decreased from 16 +/- 4 to 6 +/- 3 mm Hg (p < 0.001). The mitral valve area (MVA) by catheter increased from 0.7 +/- 0.2 to 1.7 +/- 0.5 cm2 (p < 0.001), and MVA as determined by echocardiography (2DE) increased from 0.8 +/- 0.1 to 1.9 +/- 0.3 cm2 (p < 0.01). There were no deaths or thromboembolic complications; cardiac tamponade developed in one patient, mild mitral regurgitation (MR) developed in three patients (10%) and increased by one grade from (1+ to 2+) in another two patients (8%). A small atrial septal defect (ASD) assessed by color flow mapping developed in seven patients (25%); 90% were closed at 3 months. The Doppler and 2DE MVAs were maintained at 1.8 +/- 0.4 cm2 at 17 months' mean follow-up; one patient developed restenosis. We conclude the PMV using the Inoue balloon catheter is safe and effective in the treatment of severe mitral stenosis in children, with a low complication rate.

Intravascular stents have been implanted in children with congenital and acquired vascular stenoses. Little information is known regarding the long-term results in growing patients, the implantation of multiple stents (in series), and the feasibility of further dilation. Nine stents were implanted in the abdominal aortas of 6 mini-pigs; in 3 pigs, 2 stents were implanted in series. Five pigs were recatheterized 196 +/- 17 days after stent implant. All stents were patent, with mild narrowing at the stent relative to the adjacent aorta; further stent dilation was performed. The stent diameter increased from 8.3 +/- 0.6 mm to 11.2 +/- 1.3 mm (p = 0.002), and the narrowing was relieved. These five pigs were catheterized 253 +/- 73 days after stent redilation. Each stent was patent without narrowing or pressure gradient. We conclude that intravascular stents do not interfere with normal growth, can be implanted in series, and can be further dilated.

Between November 1985 and December 1991, percutaneous balloon mitral valvuloplasty (PBMV) with the Inoue balloon catheter (Toray Marketing & Sales [America], Inc., New York, N.Y.) was performed in 53 patients with rheumatic mitral stenosis and associated mild to moderate aortic regurgitation. Mean left atrial pressure was 22.5 +/- 8.6 mm Hg and 9.7 +/- 5.5 mm Hg before and after PBMV, respectively (p < 0.001). The mean diastolic mitral gradient as determined by the catheter method decreased from 18.7 +/- 11.4 mm Hg to 2.1 +/- 3.1 mm Hg (p < 0.001). The echocardiographic mitral valve area was 1.0 +/- 0.2 cm2, 2.0 +/- 0.6 cm2, and 1.9 +/- 0.5 cm2, before and after PBMV and at follow-up (p < 0.001 before PBMV vs after PBMV and at follow-up). The mean diastolic mitral gradient as determined by two-dimensional and Doppler echocardiography was 19.3 +/- 8.4 mm Hg, 5.2 +/- 4.1 mm Hg, and 6.6 +/- 3.3 mm Hg, before and after PBMV and at follow-up, respectively (p < 0.001). The phonocardiographic interval between the Q wave and the mitral component of the first heart sound was 85.2 +/- 15.2 msec, 74.2 +/- 13.4 msec, and 72.3 +/- 15.7 msec before and after PBMV and at follow-up (p < 0.001 before PBMV vs after PBMV and at follow-up). The phonocardiographic interval between the aortic second sound and opening snap was 73.4 +/- 18.1 msec, 88.7 +/- 9.6 msec, and 92.1 +/- 11.7 msec before and after PBMV and at follow-up (p < 0.001 before PBMV vs after PBMV and at follow-up). The voltage of P loop in the frontal plane of the vectorcardiogram was 0.25 +/- 0.04 mV, 0.21 +/- 0.04 mV, and 0.20 +/- 0.03 mV before and after PBMV and at follow-up (p < 0.001 before PBMV vs after PBMV and at follow-up). The New York Heart Association classification improved from class II in 26 patients and class III in 27 patients before PBMV to class I in 48 patients and class II in five patients after PBMV. These hemodynamic, noninvasive, and clinical results were not significantly different from those that were obtained in 112 patients with mitral stenosis without associated aortic regurgitation, who were studied during the same period in our cardiac catheterization laboratory. It was concluded that patients with rheumatic mitral stenosis are suitable candidates for PBMV whether or not they have associated aortic regurgitation of mild to moderate degree.

The results of percutaneous mitral valvotomy by means of the Inoue single-balloon (N = 85, group 1) and the double-balloon (N = 322, group 2) techniques were compared in a nonrandomized study. The groups were not significantly different with regard to age, sex, calcification, or hemodynamic values before percutaneous mitral valvotomy. After percutaneous mitral valvotomy, patients in both groups had significant hemodynamic and clinical improvement. The increases in mitral valve area and cardiac output and the decreases in mitral valve gradient, mean pulmonary artery pressure, and mean left atrial pressure were greater in group 2. Mitral valve area determined by the Gorlin method increased 191% in group 2 and 106% in group 1; Doppler-determined mitral valve area increased 133% in group 2 and 98% in group 1. Optimal results were achieved in 93% of the patients in group 2 and 76% in group 1 (p less than or equal to 0.0001). In group 1, 6% of patients had a left-to-right shunt as shown by angiography versus 14% in group 2 (p less than or equal to 0.05). In group 2, 46% of patients had at least a 1+ increase in mitral regurgitation versus 52% in group 1. Among the patients who had an increase in mitral regurgitation, 36% of those in group 1 versus 9% in group 2 had a 2+ or more increase (p less than or equal to 0.001). The mean balloon diameter to anulus ratio was larger in group 2, and the larger the balloon diameter to anulus ratio, the greater the increase in mitral valve area.(ABSTRACT TRUNCATED AT 250 WORDS)