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ObjectiveMitral stenosis increases the risk of atrial fibrillation (AF) and stroke. Large data underlying the trend in incidence, treatment and outcomes of mitral stenosis are lacking.MethodsBased on the Health Insurance Review and Assessment Service database in Republic of Korea, patients who were diagnosed with mitral stenosis between 2007 and 2016 were enrolled. Trends in the incidence rate and changing patterns of treatment and outcome for stroke and systemic embolism and intracranial haemorrhage (ICH) were analysed.ResultsA total of 42 075 patients (mean age 60.7±13.5 years, 13 303 (31.6%) male) were included in the present study. The number included 27 824 (66.1%) patients with mitral stenosis and comorbid AF. The age-standardised annual incidence rate per 100 000 of mitral stenosis in Korea decreased remarkably from 10.3 to 3.6 over 10 years. The use of anticoagulation therapy increased consistently. The annual incidence of stroke and systemic embolism showed signs of plateau, while the incidence of ICH increased.ConclusionsThe overall incidence rate of mitral stenosis in Korean population has decreased remarkably. As increasing the use of vitamin K antagonist, the annual incidence rate of ICH was increased but the rate of stroke incidence reached a plateau. Alternative effective anticoagulation strategy should be investigated.

Cardiologists’ perception of the risk of stroke in rheumatic heart disease (RHD) is influenced more by anecdote and opinion than by the evidence.1 Despite data indicating a similar, if not a lower risk of stroke, even among the potentially highest-risk patients with RHD (those with mitral stenosis (MS) and atrial fibrillation (AF)),1 there is a pervasive belief that they may be at the ‘highest risk of thromboembolism’.2 As a consequence, in current practice, any patient with significant valvular heart disease and AF (valvular AF) becomes a candidate for long-term oral anticoagulation, without further risk stratification . The perception of very high stroke risk in RHD is also reinforced by estimates of stroke burden, which are based on extrapolation from the proportion of stroke admissions who have RHD (3%–8%),3 rather than the proportion of strokes attributable to RHD in the community (1%–2%).4 Contemporary data on stroke risk in RHD are therefore needed to realign risk perceptions to reality, to aid in risk stratification and to help make decisions on long-term anticoagulation. The study by Vasconcelos and colleagues in this issue of Heart is therefore a welcome addition to the literature in this area.5 Patients with valvular AF have a risk of stroke similar to that of those with non-valvular AF. Data from the Framingham study showed that the absolute risk of stroke was 4.5 per 100 patient-years among patients with MS and AF, similar to the risk in those with non-valvular AF (4.2 per 100 patient-years).6 In passing, it is worth noting that most references …

Atrial fibrillation (AF) is frequent in patients with rheumatic mitral stenosis (MS). Pressure overload leads to marked structural and electrical remodelling of left atrium. The frequency of persistent AF increases with age and paroxysmal, asymptomatic, AF seems even more frequent. The occurrence of AF worsens the haemodynamic tolerance of MS and markedly increases the risk of thromboembolic events. AF has a negative impact on the natural history of MS and on its outcome after commissurotomy. The respective indications of rhythm and rate control should be adapted to patient characteristics, particularly the consequences of MS, and take into account the high risk of recurrence of AF. Oral anticoagulant therapy is mandatory when AF complicates MS, regardless of its severity and CHA2DS2-VASc score. Non-vitamin K antagonists oral anticoagulants are not recommended in moderate-to-severe MS due to the lack of data. Percutaneous mitral commissurotomy does not appear to prevent the occurrence of AF in MS but should be considered as the first-line therapy when AF is associated with severe symptomatic MS, followed by the discussion of cardioversion or ablation. AF ablation should be considered in patients with mitral disease requiring intervention, but the ideal timing and techniques are difficult to determine due to the lack of appropriate specific randomised trials in patients with MS.

The severity of stenosis or regurgitation, the presence of symptoms and the consequences on the left ventricle are the main drivers of decision-making for the management of valvular diseases in current guidelines.1 2 Interventions are generally considered in severe valvular diseases and most publications focus therefore on severe lesions, although more attention is now paid on moderate valvular disease, in particular regarding aortic stenosis. The originality of the paper by Taylor et al 3 is to also analyse the prognostic impact of the least severe valvular heart disease, that is, mild valvular disease, as well as calcific valve lesions without functional effect on the same valve, that is, aortic sclerosis and mitral annular calcification (MAC). Separating functional and anatomical valvular lesions is challenging since there is a close interaction between valve function and anatomy. As an illustration, the quantification of calcium burden using the calcium score is now recommended to assess aortic stenosis severity, which is complementary to echocardiography.1 2 Nevertheless, the definitions used in the paper by Taylor et al allow for separate assessment of the prognostic impact of the severity of valvular disease and of the extent of calcific valve lesion. Mild valvular disease and anatomical lesions without functional consequences can be studied only by using systematic echocardiographic screening, which is an important feature of the OxValve cohort. Although this is not current recommended practice, a reliable detection of valvular disease requires systematic echocardiography, with only 10% of valvular disease detected by cardiac auscultation. This is particularly true for mild valvular disease and calcific valve lesions, which are …

Objectives Rheumatic mitral stenosis (MS) is a progressive disease, and risk of death may persist despite relief of the obstruction. Net atrioventricular compliance (C n ) modulates the overall haemodynamic burden of the MS and may be useful in predicting cardiovascular death after percutaneous mitral valvuloplasty (PMV). Methods A total of 427 patients (mean age 50±16 years, 84% female) with severe MS undergoing PMV were enrolled. Doppler-derived C n was estimated at baseline using a previously validated equation. The primary endpoint was late cardiovascular death, and the secondary endpoint was a composite of all-cause mortality, mitral valve (MV) replacement or repeat PMV over a median follow-up of 31 months (IQR: 7.8–49.2 months). Results At baseline, 209 patients (49%) were in New York Heart Association (NYHA) functional class III or IV. During follow-up, 49 patients died (41 cardiovascular deaths), 50 underwent MV replacement and 12 required repeat PMV, with an overall incidence of cardiac mortality and adverse events of 4.1 deaths and 11.1 events per 100 patient-years, respectively. Low baseline C n was a strong predictor of both cardiac death (adjusted HR 0.70, 95% CI 0.49 to 0.86) and composite endpoint (adjusted HR 0.81, 95% CI 0.67 to 0.91) after adjusting for clinical factors, baseline pulmonary artery pressure, tricuspid regurgitation severity, right ventricular function and immediate procedural haemodynamic data. The inclusion of C n in a model with conventional parameters resulted in improvement in 5-year cardiovascular mortality risk prediction. Conclusions Baseline C n is a strong predictor of cardiovascular death in patients with MS undergoing PMV, independent of other prognostic markers of decreased survival in MS, including baseline patient characteristics and postprocedural data. C n assessment therefore has potential value in evaluation of cardiovascular mortality risk in the setting of MS.

Percutaneous mitral commissurotomy (PMC) is the first-line therapy for managing rheumatic mitral stenosis. Over the past two decades, the indications of the procedure have expanded to include patients with unfavourable valve anatomy as a consequence of epidemiological changes in patient population. The procedure is increasingly being performed in patients with increased age, more deformed valves and associated comorbidities. Echocardiography plays a crucial role in patient selection and to guide a more efficient procedure. The main echocardiographic predictors of immediate results after PMC are mitral valve area, subvalvular thickening and valve calcification, especially at the commissural level. However, procedural success rate is not only dependent on valve anatomy, but a number of other factors including patient characteristics, interventional management strategies and operator expertise. Severe mitral regurgitation continues to be the most common immediate procedural complication with unchanged incidence rates over time. The long-term outcome after PMC is mainly determined by the immediate procedural results. Postprocedural parameters associated with late adverse events include mitral valve area, mitral regurgitation severity, mean gradient and pulmonary artery pressure. Mitral restenosis is an important predictor of event-free survival rates after successful PMC, and repeat procedure can be considered in cases with commissural refusion. PMC can be performed in special situations, which include high-risk patients, during pregnancy and in the presence of left atrial thrombus, especially in centres with specialised expertise. Therefore, procedural decision-making should take into account the several determinant factors of PMC outcomes. This paper provides an overview and update of PMC techniques, complications, immediate and long-term results over time, and assessment of suitability for the procedure.

Mitral stenosis increases the risk of atrial fibrillation (AF) and stroke. Large data underlying the trend in incidence, treatment and outcomes of mitral stenosis are lacking.Based on the Health Insurance Review and Assessment Service database in Republic of Korea, patients who were diagnosed with mitral stenosis between 2007 and 2016 were enrolled. Trends in the incidence rate and changing patterns of treatment and outcome for stroke and systemic embolism and intracranial haemorrhage (ICH) were analysed.A total of 42 075 patients (mean age 60.7±13.5 years, 13 303 (31.6%) male) were included in the present study. The number included 27 824 (66.1%) patients with mitral stenosis and comorbid AF. The age-standardised annual incidence rate per 100 000 of mitral stenosis in Korea decreased remarkably from 10.3 to 3.6 over 10 years. The use of anticoagulation therapy increased consistently. The annual incidence of stroke and systemic embolism showed signs of plateau, while the incidence of ICH increased.The overall incidence rate of mitral stenosis in Korean population has decreased remarkably. As increasing the use of vitamin K antagonist, the annual incidence rate of ICH was increased but the rate of stroke incidence reached a plateau. Alternative effective anticoagulation strategy should be investigated.

Learning objectives Non-invasive imaging Patients with valvular heart disease (VHD) can be asymptomatic or present with a wide range of symptoms that may not correlate with the severity of valve dysfunction. Transthoracic echocardiography (TTE) and transoesophageal echocardiography (TEE) combining 2D, 3D and Doppler evaluation provide the clinician with valuable and complimentary information on heart valve structure, function and the physiological consequences of the valvular lesion. This non-invasive methodology provides crucial information during the initial clinical evaluation and at follow-up. Current guidelines recommend TTE as the initial diagnostic test to evaluate patients with known or suspected VHD.1 ,2 While 2D and M-mode TTE can assess valvular motion, morphology and pathology (when present), Doppler provides requisite information on valve haemodynamics, flow velocities across the valve, pressure gradients and calculation of valve area as well as haemodynamic data regarding pulmonary artery pressure and left ventricular (LV) filling parameters. In addition, colour flow Doppler and spectral Doppler provide critical information on valve regurgitation and stenosis severity. Exercise Doppler echocardiography is useful to assess the impact of exercise on valvular and ventricular function as well as the patient's functional capacity. The severity of a valvular lesion is determined using a multiparameter echo Doppler assessment. ### Aortic stenosis Echocardiography is the imaging modality of choice for diagnosing and estimating the severity of aortic stenosis (AS). The different echocardiographic methods used for evaluation of the aortic valve (AV) for the presence of stenosis are detailed in table 1. TTE is the most well-established imaging modality for evaluating and assessing the severity of AS.1 As shown in figure 1, valve anatomy should …

Objective We analysed long-term results of percutaneous mitral commissurotomy (PMC) performed because of mitral restenosis after previous commissurotomy. Design Follow-up of a prospective cohort. Setting Tertiary university hospital. Patients We studied 163 consecutive patients who underwent PMC because of restenosis occurring 16±8 years after previous commissurotomy (closed-heart in 121, open-heart in 30 and PMC in 12). Mean age was 48±14 years; 62 patients (38%) had valve calcification. Restenosis was due to bicommissural fusion in all cases. Intervention PMC using a single or double balloon in 80 patients and the Inoue balloon in 83. Results Good immediate results (IR) (valve area ≥1.5 cm2 with MR≤2/4) were obtained in 135 pts (83%). 20-year rates were 27.9±4.7% for cardiovascular survival without mitral surgery and 14.8±3.9% for good functional results (cardiovascular survival without reintervention on the mitral valve and in New York Heart Association (NYHA) class I or II). After good IR, 20-year rates were 33.2±5.5% for cardiovascular survival without surgery and 17.9±4.7% for good functional results. After good IR, multivariate predictive factors of poor late functional results were higher NYHA class (p=0.01), atrial fibrillation (p=0.0002) and higher mean mitral gradient after PMC (p=0.004). Conclusions In patients with restenosis after mitral commissurotomy, PMC provides good IR in most cases. After good IR, one patient out of three remains free from surgery and one out of five has good functional results at 20 years. These findings support the use of PMC after previous commissurotomy, particularly in selected patients with few symptoms and in sinus rhythm.

To compare mitral valve area (MVA) measurements obtained by 2D transthoracic planimetry and 3D transoesophageal echocardiography (TOE) in patients with mitral stenosis (MS), and to determine the causes of discrepancies between the two techniques.Reliability and agreement study.Tertiary referral centre.Eighty-seven patients with MS.MVA was determined by transthoracic 2D planimetry and 3D TOE. Clinical and echocardiographic variables were evaluated. The angle (Mα) between the lines of the true mitral valve (MV) tip and the echo beam-to-MV tip was measured at early diastole from the parasternal long-axis view obtained from 2D echocardiography.Although MVA measurements using 2D planimetry and 3D TOE showed good agreement (intraclass correlation coefficient, 0.853; p0.001), 2D planimetry overestimated MVA by 0.19±0.2 cm(2) compared with 3D TOE (p0.001). Left atrial (LA) dimension obtained from the parasternal long-axis view at end-systole (p=0.012), Mα (p0.001), and left ventricular ejection fraction (p=0.022) were independent determinants of the MVA difference (MVA by 2D-MVA by 3D TOE; MVA(2D-3D)) according to multiple linear regression analysis. The LA dimensions correlated with Mα (r=0.352, p=0.001). The best cut-off values for predicting significant overestimation by 2D planimetry (MVA(2D-3D)0.2 cm(2)) were LA dimension ≥49 mm (78% sensitivity, 72% specificity) and Mα≥9.5° (56% sensitivity, 89% specificity).Because 2D planimetry tends to overestimate MVA, 3D TOE should be considered for accurate MVA assessment, especially in patients with a large LA and large Mα.

Background Percutaneous mitral valvuloplasty (PMV) is an attractive therapeutic option for mitral stenosis (MS). Objective To investigate the incidence and development of tricuspid regurgitation (TR) long after successful PMV. Design, patients and interventions A prospective cohort of 299 patients with symptomatic MS who underwent successful PMV as first-line treatment between 1988 and 2010. Setting One tertiary university hospital. Main outcome measures Significant TR, defined as a grade ≥3 on echocardiographic analysis. Results Although most TR regressed in these patients immediately after the procedure, 56 patients developed significant TR during follow-up (median 12 years, IQR 8.0–18.0 years). The cumulative incidence of significant TR increased time-dependently (9.4%, 19.8% and 35.2% at 8, 12 and 18 years of follow-up, respectively). Atrial fibrillation (AF) and TR grade ≥2 before PMV were found to be independent predictors of significant TR (HR (95% CI) 3.049 (1.169 to 7.949) and 3.016 (1.303 to 6.982), p=0.023 and 0.010 for pre-PMV AF and pre-PMV TR grade ≥2, respectively). Even after, exclusion of patients with significant TR at baseline, pre-PMV TR grade ≥2 and AF remained important factors of de novo TR development. Mitral valve restenosis was also associated with late significant TR development. Conclusions Significant TR after successful PMV in patients with MS is not uncommon long after PMV. TR development is closely associated with mitral valve restenosis. More attention should be paid during long-term follow-up to TR development in patients with MS who have significant pre-PMV TR and/or AF.

Left atrial (LA) volume is an independent prognosticator in various cardiac diseases. The authors assessed the changes of LA volume after successful percutaneous mitral valvuloplasty (PMV) and the impact of LA enlargement on long-term clinical outcome after PMV.From a prospective PMV registry started in 1988, 303 patients (242 women, age: 39.3+/-10.8 years) who had undergone successful PMV were followed for 4-20 years (median 11 years). Echocardiographic examination including LA volume measurement was performed before PMV and repeated after PMV. LA volume decreased from 92+/-50 to 69+/-42 ml (p0.001) immediately after PMV and remained stationary until 1 year after PMV. Since then, LA volume subsequently increased exceeding the pre-PMV level by 8 years after PMV. Multivariate analysis showed that LA volume increase at 10 years after PMV was independently related to the post-PMV mitral valve area, the echo score, the presence of atrial fibrillation and post-PMV LA volume. On multiple regression analysis, pre-PMV LA volume and percentage change of LA volume immediately after PMV emerged as independent predictors of event-free survival along with age, pre-PMV tricuspid regurgitation and post-PMV mitral valve area. Ten-year survival rate was 93% in patients with smaller LA before PMV (or =72 ml/m(2)), whereas it was only 60% in those with larger LA (72 ml/m(2)).Progressive increase of LA volume was observed even after successful PMV. Larger pre-PMV LA volume was associated with poor prognosis.

Objective: To determine the prevalence of rheumatic heart disease (RHD) among school children in urban and semiurban areas of Lahore, Pakistan. Methods: A cross-sectional survey of school children aged 5–15 years from 70 schools of urban and semiurban Lahore was carried out by a team of cardiologists. Children were screened by clinical examination and diagnosis confirmed by echocardiography. Sociodemographic data were also collected. Results: Of 24 980 children screened, 986 (3.9%) had a confirmed cardiac lesion; 546 had RHD, 440 had congenital heart disease. The prevalence of RHD was 21.9/1000 children screened (95% CI 20.1 to 23.7). Their mean (SD) age was 10.7 (2.6) years and the female:male ratio was 1.6:1. Most (92.5%) were unaware of the diagnosis and less than 2% were taking rheumatic prophylaxis. All children belonged to a low socioeconomic group and 67% were undernourished. Conclusion: The prevalence of RHD in the urban school population of Lahore is among the highest in the world. The younger age of onset is a special feature and most are unaware of the diagnosis, and hence not receiving life-saving secondary prophylaxis.

Stress testing is a cornerstone in the evaluation of patients with coronary artery disease and its results are always integrated into any clinical decisions. In contrast, valvular heart disease is usually considered static and its management relies upon resting evaluation only. However, most valve diseases have a dynamic component. Changes in loading conditions and contractility during a patient’s life may lead to alterations in the severity of lesions, good or poor ventricular contractile reserve, altered volume-dependent compliance of heart chambers, and ventricular arterial coupling. Thus, there may be a need for stress testing and imaging in this setting. Exercise testing in particular can induce symptoms, reveal the dynamics of the valve and the ventricle, and evaluate the changes in forward output, retrograde flow and pulmonary pressures. The current primary role of stress testing in valve disease is to provide an objective assessment of functional disability which is of the utmost importance in patients who often adapt and reduce their physical activity, thus masking their symptoms. The Euro Heart Survey on valvular disease recently showed that stress testing is underused in Europe, or used for inappropriate purposes.1 The following questions will be addressed for each of the left valvular heart diseases: ### Asymptomatic severe aortic stenosis #### Who needs stress testing? Valve replacement is required in the presence of symptoms and severe aortic stenosis. In such patients, stress testing is contraindicated. In contrast, exercise testing is recommended in asymptomatic patients with severe aortic stenosis. Exercise is strongly advocated in the European guidelines2 and is a grade IIb recommendation in the American College of Cardiology/American Heart Association (ACC/AHA) 2006 guidelines. …

The haemodynamic consequences of atrial fibrillation in patients with mitral stenosis have received little attention despite their clinical significance. What role does rhythm control have in the treatment of these patients?

To investigate the value of transoesophageal echocardiography in the assessment of commissural morphology and prediction of outcome after balloon mitral valvotomy (BMV).Prospective study.Tertiary cardiac referral centre.72 consecutive patients (mean age 61.3 years, range 38-89 years) referred for BMV.Transoesophageal echocardiography was performed immediately before BMV and the mitral commissures were scanned systematically. Anterolateral and posteromedial commissures were scored individually according to whether non-calcified fusion was absent (0), partial (1), or extensive (2). Calcified commissures usually resist splitting and scored 0. Scores for each commissure were combined giving an overall commissure score for each valve of 0-4, higher scores reflecting increased likelihood of commissural splitting. Valve anatomy was also graded by the method of Wilkins et al, which does not include commissural assessment.Patients were divided into outcome groups: A (good) and B (suboptimal). "Good" was defined as final valve area1.5 cm2 with a25% increase in area and absence of severe mitral regurgitation judged by echocardiography.Valve area increased from a mean (SD) of 1.1 (0.28) cm2 to 1.8 (0.46) cm2. Commissure scores were higher in group A than in group B (p0.01), scoresor = 2 predicting a good outcome with positive and negative accuracy of 67% and 82%, respectively (p0.001). Commissure score was the strongest independent predictor of outcome.Transoesophageal echocardiographic assessment of commissural morphology predicts outcome after BMV, adding significantly to the Wilkins score.

To assess the safety, efficacy, and long term results of mitral balloon valvotomy (MBV) for rheumatic mitral stenosis in children and adolescents in comparison to adults.The results of 468 patients with mitral stenosis who underwent successful MBV and were followed up for 0.5-13 years were analysed. Patients were divided according to age at the time of MBV into group 1 consisting of 84 patientsor = 20 years of age (children and adolescents) and group 2 that included 384 patients, age20 (adults).Patients in group 1 had a lower mitral echo score (mean (SD) 7.5 (1.3) v 8 (1.1), p0.001), smaller Doppler mitral valve area (MVA) (0.84 (0.17) v 0.92 (0.18) cm2, p0.001), and higher Doppler mitral valve gradient (15.0 (5.3) v 12.7 (4.5) mm Hg, p0.001) than group 2. Immediately after MBV group 1 had larger MVA, whether measured by Doppler (2.0 (0.30) v 1.96 (0.28) cm2, p0.05) or by catheter (2.0 (0.59) v 1.8 (0.52) cm2, p0.001), and similar complication rates, compared to group 2. After a mean follow up of 5 (3.5) years there was no significant difference between groups 1 and 2 in the incidence of restenosis (14.3% v 16.1%, NS). Event-free survival rates at 5, 10, and 12.5 years were 93%, 79%, and 79% for group 1 and 94%, 90%, and 84% for group 2 (p = 0.18).MBV is safe and effective in children and adolescents with rheumatic mitral stenosis. It provides better immediate results than in adults and excellent long term results that are comparable to those seen in adults.

Degenerative mitral valve disease is responsible for the syndromes of billowing mitral leaflet, mitral valve prolapse (MVP), floppy mitral valve, and flail leaflet.1–6 The pathology of these is mainly caused by myxomatous infiltration and fibroelastic deficiency. In the 1960s, Reid7 and Barlow and colleagues1 proposed that mid to late systolic clicks and apical late systolic murmurs were of mitral valvar origin. This origin was further documented by intracardiac phonocardiography.8 Criley and colleagues used “mitral valve prolapse” to describe posterior mitral leaflet motion in systole.9 Since then, MVP has remained a diagnosis of sustained interest and controversy. Because MVP is asymptomatic or has a non-specific clinical presentation, the disease is often detected by the non-ejection systolic click of the mitral valve and the late systolic murmur. MVP is clinically benign with potential for serious complications in otherwise healthy people, such as degenerative mitral regurgitation and infective endocarditis. Age and sex distributions as well as the frequencies of chest pain, dyspnoea, and ECG abnormalities were not significantly different between subjects with and without MVP,10–12 demonstrating that the previously reported associations were probably caused by a selection bias. These recent studies also showed that patients with MVP had lower body mass index than those without MVP. Many disorders have been associated with MVP but we do not know whether these associations are a casual coincidence, a common link or an expression of a genetic disturbance. Histologic patterns of degenerative mitral valve disease include myxomatous infiltration, fibroelastic deficiency, collagen alterations, and mucopolysaccharide accumulation.13 Elongated or ruptured chordae are often associated with these abnormalities. Because the distribution of mitral leaflet layers, namely auricularis, spongiosa, fibrosa, and ventricularis, is different in the basal, middle, and distal thirds of the leaflet, histologic abnormalities may vary accordingly. Myxomatous infiltration …

Percutaneous balloon mitral valvuloplasty is now the treatment of choice for many patients with symptomatic mitral stenosis Applications are expanding to include several categories of patients previously considered ineligible for the procedure. Commissural fusion is now recognised as the principal pathology underlying mitral stenosis, and commissural splitting underlies successful interventional treatment. Although the technique of surgical commissurotomy was first described as early as 1948,1 percutaneous commissurotomy became a feasible option with the advent of the Inoue balloon in 1984.2 Percutaneous balloon mitral valvuloplasty (PBMV) is now the treatment of choice for many patients with symptomatic mitral stenosis. Numerous large series have reported excellent short, medium, and long term outcome3–7 with a low incidence of serious complications.8 Furthermore, randomised trials comparing balloon valvuloplasty with the surgical alternatives of open or closed commissurotomy have demonstrated equivalent outcome,9,10 although patients treated using the percutaneous approach enjoy the advantages of reduced procedural morbidity and mortality and a short hospital stay. Specific advantages of the Inoue balloon in comparison with other percutaneous techniques include a lower risk of complications (particularly left ventricular perforation which is more frequent using double balloon techniques), easier manoeuvrability, its slender profile (creating a smaller defect in the interatrial septum), its self positioning characteristics, short inflation–deflation cycle, and capacity to permit gradually increasing successive balloon inflation sizes, which allow the operator to terminate the procedure when commissural splitting is achieved or when there is an increase in the severity of mitral regurgitation. Disadvantages include circumferential application of pressure during balloon inflation, occasionally resulting in paracommissural tears, especially in degenerate, calcified valves. In developing nations, the application of PBMV is frequently limited on account of the high cost of the Inoue balloon. The development of a percutaneous metallic valvulotome, which can be autoclaved after each …

Although there is very little high quality evidence to guide the medical treatment of valve disease, this is an important area of cardiology for two reasons. Firstly, there are many frail older people with symptomatic degenerative valve disease in whom the risks of surgical intervention are prohibitive and medical treatment is the only realistic option. Secondly, there is a real and exciting prospect of using medical treatment to influence the natural history of some forms of valve disease, thereby delaying or even avoiding the need for surgery. Left ventricular systolic dysfunction caused by ischaemic heart disease was the underlying problem in the vast majority of patients who took part in the landmark trials of medical treatment (angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor antagonists, vasodilators, β blockers, and spironolactone) for heart failure. However, some of these trials included patients with valve disease and the principles that have been learned may be widely applicable. Thus, it seems reasonable to assume that a small dose of spironolactone will benefit most patients with severe congestive cardiac failure including those with valvar heart disease. On the other hand it seems clear that the characteristic haemodynamic problems associated with individual valve lesions may influence the relative benefits and hazards of specific treatments. For example, vasodilator treatment may be unwise in patients with severe aortic stenosis because there is a risk that this will reduce aortic pressure and coronary perfusion without an equivalent reduction in the left ventricular afterload. In contrast, vasodilators may be particularly beneficial in patients with aortic or mitral regurgitation because they might be expected to reduce the regurgitant fraction and increase forward flow. Similarly, by prolonging diastole and left ventricular filling, β blockers may harm patients with aortic regurgitation but benefit patients with mitral stenosis. Medical treatment might be able to alter …

OBJECTIVE—To evaluate the significance of commissural calcification, identified by transthoracic echocardiography, on the haemodynamic and symptomatic outcome of mitral balloon valvotomy. METHODS—Commissural calcification was graded from 0-4 using parasternal short axis transthoracic views. The morphology of the mitral valve was also assessed using the Massachusetts General Hospital echo score. SETTING—A tertiary cardiac centre in Scotland. PATIENTS—300 patients were studied, 85 retrospectively and 215 prospectively. Mean (SD) age was 59.8 (12.7) years, range 13 to 87; 30% had been judged unsuitable for surgery. Median echo score was 6.8 (3.0), range 2-16. MAIN OUTCOME MEASURES—Immediate increase in mitral valve area and in New York Heart Association functional class 1-3 months after balloon valvotomy. RESULTS—On univariate and multivariate analysis, commissural calcification grade was a significant predictor of achieving a mitral valve area of > 1.50 cm2 without severe mitral reflux. Its influence was greatest in patients with an echo score ⩽ 8: those with commissural calcification grade 0/1 had significantly greater improvement in valve area and symptom status than those with grade 2/3; the proportions of patients achieving a final valve area of > 1.50 cm2 were 67% and 46%, respectively (p 8, the influence of commissural calcification was smaller and not significant. CONCLUSIONS—Commissural calcification as assessed by transthoracic echocardiography is a useful predictor of outcome in patients with otherwise "good" valves (echo score ⩽ 8). Calcification of one commissure or more predicts a less than 50% probability of achieving a valve area above 1.50 cm2 and is an indication for valve replacement in those who are suitable for surgery. Keywords: mitral balloon valvotomy; commissure calcification

OBJECTIVE: To evaluate the effectiveness and safety of percutaneous balloon mitral commissurotomy for the treatment of pregnant women with severe mitral stenosis over a period of six years. DESIGN: Analysis of clinical, haemodynamic, and echocardiographic data before and immediately after the procedure, the pregnancy outcome, and the fate of newborn babies. SETTING: Academic cardiovascular centre in Monastir, Tunisia. PATIENTS: 44 pregnant patients who underwent percutaneous transvenous dilatation of the mitral valve between January 1990 and February 1996. Grade 2 mitral regurgitation was present in two patients and densely calcific valves in three (7%). RESULTS: Commissurotomy was successfully achieved in all cases. The total mean (SD) duration of teh procedure was 72 (18) minutes and that of fluoroscopy 16 (7) minutes. Left atrial pressure decreased from 28 (10) to 14 (7) mm Hg, mitral pressure gradient fell from 22 (8) to 5 (3) mm Hg. Cardiac output increased from 4.8 (1.1) to 6.3 (1.2) l/min and Gorlin mitral valve area from 0.96 (0.21) to 2.4 (0.4) cm2 (all P < < 0.001). Cross sectional echocardiographic mitral valve area increased from 1.07 (0.21) to 2.32 (0.36) cm2. There were no maternal or fetal deaths. Complications included a grade 4 mitral regurgitation in one patient that required early valve replacement. All patients delivered at full term, 42 vaginally and two (5%) by caesarean section; 41 babies were normal and three whose mothers had the procedure near term were relatively hypotrophic. At a mean follow up of 28 (12) months (range 2 to 26) all children had normal growth. CONCLUSIONS: During pregnancy, balloon mitral commissurotomy is the treatment of choice of severe pliable mitral stenosis in patients who are refractory to medical treatment.

Surgery for degenerative mitral regurgitation has become complex. Preservation of annulo-ventricular continuity through the chordae tendineae is an important determinant of operative survival, postoperative left ventricular function, long-term survival, and quality of life. Some cardiologists believe that NYHA I function is never achieved after conventional mitral replacement with chordal transection. Valve repair is the procedure of choice but when valve replacement is inevitable every effort should be made to preserve the posterior leaflet and its chordal attachments. Valve replacement with preservation of the subvalvar apparatus provides a functional outcome similar to that after valve repair but usually leads to life long anti-coagulation.

OBJECTIVE--To study the incidence of spontaneous echo contrast in left atrium of Indian patients with rheumatic mitral stenosis in normal sinus rhythm and to define its relations. SUBJECTS--Transthoracic and multiplane transoesophageal echocardiographic studies were performed in 89 consecutive patients with rheumatic mitral stenosis who were in normal sinus rhythm. RESULTS--Spontaneous echo contrast in the left atrium was seen in 57.3% of patients on multiplane transoesophageal echocardiography and in only 5.6% on transthoracic echocardiography. The mean mitral valve area was 1.07 (SD 0.33) cm2 and 1.32 (0.45) cm2 (P = 0.004), mean left atrial size was 4.27 (0.67) cm and 3.91 (0.5) cm (P = 0.029), mean diastolic pressure gradient was 12.64 (5.69) mm Hg and 10 (5.5) mm Hg (P = 0.049), and absence of mitral regurgitation was seen in 45% and 23% of patients respectively (P = 0.1). Among patients with spontaneous echo contrast, 31% had either left atrial/appendage thrombus or a history of embolism, upsilon 0% in patients without spontaneous echo contrast (P < 0.0001). CONCLUSIONS--There is a high incidence of spontaneous echo contrast in the left atrium in Indian patients with rheumatic mitral stenosis in normal sinus rhythm on multiplane transoesophageal echocardiography. These patients are likely to embolise or form thrombi in the left atrium. The presence of spontaneous echo contrast is also associated with significantly smaller mitral valve area, larger left atrium, and higher mean diastolic mitral pressure gradient.

OBJECTIVE--To assess the outcome of percutaneous balloon dilatation of the mitral valve in critically ill young patients with intractable heart failure. DESIGN--Retrospective analysis of all such patients presenting over a period of 4 years. PATIENTS--Of 432 consecutive patients undergoing percutaneous balloon dilatation of the mitral valve, 12 (mean age 29 years) with intractable heart failure were identified. Nine had severe pulmonary oedema and three had pulmonary oedema with severe right heart failure and hypotension. Three patients were pregnant and three required mechanical; ventilatory support. PROCEDURE--Percutaneous balloon dilatation of the mitral valve was performed using the Inoue balloon technique. The procedure was shortened by excluding full right study, cardiac output measurement, and left ventriculography. The mitral valve morphology and mitral valve area were determined before and after percutaneous balloon dilatation using cross sectional Doppler echocardiography. RESULTS--The procedure was technically successful in all patients. The mean (SD) echocardiographic value of the mitral valve area increased from 0.7 (0.1) to 1.4 (0.2) cm2 with a concomitant reduction in pulmonary artery systolic pressure (Doppler) from 81 (17) to 50 (7) mm Hg. There was a significant clinical improvement in all patients. The mean (range) fluoroscopy time for the procedure was 6.9 (1.7-14.1) min. During follow up (mean 10 months) nine patients were in New York Heart Association (NYHA) functional class I, one was in class II, one under NYHA elective mitral valve replacement, and one, who refused elective surgery, died suddenly at home. CONCLUSION--Percutaneous balloon dilatation of the mitral valve can be performed as a life saving procedure in critically ill patients with mitral stenosis, as even a modest increase in valve area in these patients produces gratifying clinical improvement.

Clinical introduction A 57-year-old woman with known moderate-to-severe mitral stenosis and atrial fibrillation (AF) presented to the emergency department with acute onset right loin pain after having a coronary angiogram and left and right heart catheterisation through the right femoral route about 28 h ago. The cardiac catheterisation was done after she presented with one episode of troponin-negative chest pain and progressive shortness of breath. She had anterior wall myocardial infarction (MI) 25 years ago, which was thought to be due to coronary artery embolism. Her mitral stenosis was diagnosed at that stage. Her warfarin was stopped for 5 days before cardiac catheterisation and international normalised ratio (INR) on the day of the procedure was 1.1. No bridging heparin/low molecular weight heparin (LMWH) was used and warfarin was restarted on the evening of the procedure at the usual dose. Clinical examination revealed some guarding in the right iliac fossa and some tenderness in the right loin. She was not feverish and there was no dysuria or frequency. There was no lump at the puncture site. On presentation to the emergency department, a contrast-enhanced CT scan of the abdomen was performed (figures 1 and 2). Question Which of the following is the aetiology of the pain? Abdominal aortic dissection Renal artery embolism Retroperitoneal haematoma Ureteric stone

OBJECTIVES--To compare the use of cylindrical balloons and the Inoue balloon for percutaneous mitral valvotomy in patients in the United Kingdom. DESIGN--Comparison of the haemodynamic results, complications, and symptomatic outcome of balloon dilatation for mitral stenosis in consecutive patients treated by cylindrical balloons and a second consecutive series of patients treated by the Inoue balloon. SETTING--A tertiary cardiac referral centre in Scotland. PATIENTS--70 patients (mean age 60.6 years) treated by the single or double cylindrical balloon technique and 70 patients (mean age 58.9 years) treated with the Inoue balloon method. MAIN OUTCOME MEASURES--Success in obtaining dilatation at the mitral orifice, procedure and screening times, increase in valve area, complications, and early symptomatic outcome. RESULTS--Dilatation of the mitral valve was obtained in 91% of patients when cylindrical balloons were used and in 99% of patients treated with the Inoue balloon. Use of the Inoue balloon gave significantly shorter procedure and screening times. Technical problems in obtaining and maintaining the position at the mitral orifice were more common with cylindrical balloons. Improvements in valve area and symptoms were not significantly different with use of the two types of balloon. The Inoue balloon avoided cardiac tamponade and the creation of larger atrial septal defects, but had a higher incidence of increase in mitral reflux. CONCLUSIONS--In these elderly patients, the Inoue balloon method was safer and faster for percutaneous mitral valvotomy, with a higher success rate for dilatation within the valve orifice. Haemodynamic and symptomatic improvement was similar with the two techniques.

OBJECTIVE--To assess the outcome after attempted percutaneous balloon dilatation of the mitral valve in patients with severe mitral stenosis between February 1986 and June 1992. DESIGN--Clinical state, mitral valve area, and restenosis at follow up were analysed. Mitral valve area as determined by the Gorlin formula, planimetry, and Doppler methods was compared before and after dilatation and at follow up. SETTING--University hospital. PATIENTS--176 patients had serial clinical and Doppler echocardiographic follow up and 44 of them also underwent recatheterisation. RESULT--At follow up 93% of patients were in New York Heart Association functional class I or class II. Mitral valve area (planimetry) increased from 0.97(0.24) cm2 before to 1.86(0.39) cm2 after dilatation (p = 0.0001) and then decreased to 1.72(0.39) cm2 at follow up (p < 0.001); mitral valve area (Doppler) increased from 1.01 (0.24) to 1.89 (0.42) cm2 (p = 0.0001) and then decreased to 1.78(0.40) cm2 (p < 0.05). The overall restenosis rate was 15% and over 90% of the patients were free from cardiovascular events. Age, valvar calcification, echocardiographic score, and mitral valve area after dilatation were found to be determinant predictors of restenosis. In patients who underwent recatheterisation, mitral valve area by the Gorlin method at follow up was comparable with that by planimetry and Doppler methods whereas a significant discrepancy between the three methods was noted immediately after dilatation. CONCLUSION--Balloon dilatation of the mitral valve provided sustained anatomical and functional improvement in over 80% of patients at late follow up. Older age, heavy calcification, high echocardiographic score, and suboptimal immediate results are significant predictors of restenosis. Doppler echocardiographic examination is the procedure of choice for follow up evaluation.

OBJECTIVE--To examine the value of transarterial balloon dilatation of the mitral valve for treatment of patients with mitral stenosis over a period of five years. DESIGN--Analysis of patients' functional state, and haemodynamic and echocardiographic variables, before and immediately after the procedure and during a follow up of up to five years. SETTING--A cardiovascular centre in Belgrade, Yugoslavia. PATIENTS--Two hundred and ninety four patients who underwent percutaneous transarterial dilatation of the mitral valve between February 1985 and February 1990. RESULTS--Mean mitral valve area was enlarged by 109%. Complications included death (0.7%), severe mitral insufficiency (2.3%), mild mitral insufficiency (9.9%), cerebral embolism (2%), and injury to the femoral artery (2%). Two more patients died at two and 11 months after the procedure. Late cardiac surgery was needed in eight patients (mitral insufficiency in three, restenosis in three, thrombus in one, and endocarditis in one. Restenosis occurred in seven patients. Four of these underwent repeat dilatation and three had surgery. Improvement of symptoms was seen in 94% of patients during the follow up. CONCLUSION--Transarterial balloon dilatation of the mitral valve gave good results with acceptable morbidity and mortality and had some advantages over the anterograde approach.

OBJECTIVE--Systemic emboli related to atrial thrombi are a well known complication of percutaneous balloon dilatation of the mitral valve. The presence of left atrial thrombi therefore, is believed to be a contraindication to balloon dilatation. The purpose of this study was to determine the frequency of left atrial thrombi in patients referred for balloon dilatation of the mitral valve, the added benefit of pre-procedural transoesophageal echocardiography, and to identify factors that predicted left atrial thrombi. DESIGN--Prospective study over a 14 month period of 20 consecutive patients by cross sectional transthoracic echocardiography 24-48 hours before balloon dilatation of the mitral valve and by transoesophageal echocardiography immediately before the procedure. RESULTS--One patient had a left atrial thrombus detected by transthoracic study. Two patients (10%) had left atrial thrombi identified by transoesophageal echocardiography. In both valve dilatation was not attempted and the thrombi were confirmed at surgery. The remaining 18 patients all underwent successful balloon dilatation of the mitral valve without clinical evidence of an embolic event. No association was found between patient age, mitral valve area, transmitral gradient, left atrial size, presence of atrial fibrillation, severity of mitral regurgitation, cardiac output, or the presence of left atrial swirling and an increased prevalence of atrial thrombi. CONCLUSION--Left atrial thrombi are often seen despite long term systemic anticoagulation in patients referred for balloon dilatation of the mitral valve. The frequency of unsuspected left atrial thrombi detected by transoesophageal echocardiography was similar to the reported frequency of embolic events after balloon dilatation of the mitral valve. Transoesophageal echocardiography for the identification of left atrial thrombi is strongly recommended in all patients before balloon dilatation of the mitral valve including those treated with systemic anticoagulation and those who have had a normal transthoracic echocardiographic study.

Retrospective echocardiographic review identified 58 consecutive infants and children with fixed subaortic stenosis. Mean (SD) age at diagnosis was 4.8 (3.6) years (range two days to 14.7 years), and diagnosis occurred in infancy in eight. Associated cardiac abnormalities were present in 41 (71%) whereas fixed subaortic stenosis was an isolated lesion in 17 (29%). Four types of fixed subaortic stenosis were identified: short segment (47 (81%)), long segment (7 (12%)), posterior displacement of the infundibular septum with additional discrete narrowing of the left ventricular outflow tract (3 (5%)), and redundant tissue arising from the membranous septum (1 (2%)). Echocardiographic studies had been performed before the diagnosis of fixed subaortic stenosis in nine patients, all with associated abnormalities. These were performed in infancy in each and showed a "normal" left ventricular outflow tract in six and posterior deviation of the infundibular septum in three. In 16 patients serial echocardiographic studies had been performed after the diagnosis of fixed subaortic stenosis but before surgery of the left ventricular outflow tract. Rapid evolution of short segment to long segment narrowing was seen in one patient, and tethering of the aortic valve or mitral valve developed in a further four patients. Aortic valve or mitral valve involvement was not seen before the age of three years but was common thereafter (10/40 patients, 25%). Fixed subaortic stenosis may be an "acquired" lesion with the potential for changes in form as well as progression in severity of left ventricular outflow tract obstruction.

The genetic mucopolysaccharidosis syndromes (MPS) are autosomal recessive inborn errors of metabolism. Heart valve involvement in MPS is not uncommon but only a few case reports of successful cardiac surgery are available. In particular, reports of combined aortic and mitral stenosis associated with MPS type I-S are very rare. Both type I and type VI MPS are associated with significant left sided valvar heart disease that requires surgical valve replacement because of irregular valve thickening, fibrosis, and calcification. A 35 year old man had severe mitral valve stenosis after successful surgical replacement of a stenotic aortic valve. Valvar heart disease was investigated by cardiac ultrasound and left heart catheterisation. Histomorphological characterisation of the affected mitral valve was performed. The case illustrates typically associated clinical features of cardiac and extracardiac abnormalities found in MPS type I-S. Keywords: valvar disease; mucopolysaccharidosis; mitral valve stenosis; aortic valve stenosis

The efficacy of balloon dilatation of the mitral valve by a bifoil (2 x 19 mm) or trefoil (3 x 15 mm) catheter (single catheter technique) was assessed in 53 patients (mean age 28) with mitral stenosis, most of whom were women. The procedure was unsuccessful in three patients. After balloon dilatation the left atrial pressure decreased from 22 mm Hg to 13 mm Hg and the mitral valve gradient from 12 mm Hg to 4 mm Hg. The mitral valve area increased from 0.7 cm2 to 2.1 cm2. Exercise time on the standard Bruce protocol increased from 3.9 minutes to 7.2 minutes. In 22 (44%) patients mitral regurgitation developed or the grade of regurgitation increased. Left to right shunts with pulmonary to systemic flow ratios greater than 1:5 were detected in four patients. Transient cerebrovascular episodes developed in two patients. One patient died after emergency valve replacement for severe mitral regurgitation. Balloon dilatation of the mitral valve by the single catheter technique with the bifoil or trefoil catheters is an effective treatment for patients with mitral stenosis. Mild mitral regurgitation is a frequent complication of the procedure.

Mitral valve cusp separation on M mode echogram, the mitral valve opening artefact, and the onset of forward transmitral flow recorded by Doppler echocardiography have all been taken to mark the end of isovolumic relaxation, while its onset has been taken either as the aortic closure sound (A2) recorded phonocardiographically or the aortic closure artefact determined by Doppler technique. Possible differences in the measurement of the isovolumic relaxation time were studied when these landmarks were used in 44 healthy people, 14 patients with mitral stenosis, 21 patients with left ventricular hypertrophy, and 24 patients with dilated cardiomyopathy by recording M mode echograms of the mitral valve, and pulsed and continuous wave Doppler spectra of transmitral flow, with simultaneous electrocardiograms and phonocardiograms. A2 was effectively synchronous with the aortic artefact. However, when the onset of Doppler flow was regarded as the end of isovolumic relaxation, the interval was significantly longer than when mitral cusp separation on M mode echograms was used: by 25 (10) ms in healthy individuals, by 25 (15) ms in patients with left ventricular hypertrophy, and by 50 (35) ms in patients with dilated cardiomyopathy. In patients with mitral stenosis the interval was only 5 (5) ms longer. The mitral valve opening artefact consistently followed the onset of flow and corresponded much more closely to the E point on the M mode echogram. This shows that it occurred during the rapid filling period and well beyond isovolumic relaxation by any definition. Thus isovolumic relaxation time measured from A2 to the onset of transmitral flow or the mitral valve opening artefact differs from that derived from A2 to mitral valve cusp separation. These intervals cannot be used interchangeably to measure "isovolumic relaxation time".

Surgical treatment of mitral stenosis is one of the first heart operations that consistently provided relief of symptoms and improved survival. Two surgeons, Charles Bailey in Philadelphia and Dwight Harken in Boston performed the first successful closed mitral commissurotomy almost simultaneously (4 days apart) in June of 1948.1 The relief of the inflow obstruction resulted in immediate improvement of patients’ clinical picture. The initial success led to the refinement of the technique by introduction of a special valve dilatator. Tubbs from the UK perfected the valve dilatator developed by Dr Logan, which is named after him.1 ,2 Closed mitral commissurotomy is performed through a left thoracotomy in the beating heart without cardiopulmonary bypass by inserting the dilatator through the left ventricular apex and opening its arms inside the mitral leaflets. The surgeon cannot see, but feel the changes that occur in the valve by the index finger inserted in the left atrium through the appendage. The dilatation can be repeated by enlarging the dilatator's arms providing excellent long-term outcomes.3 ,4 Although closed commissurotomy is abandoned in USA and Western countries, giving way to open heart surgery, it is still in use in many parts of the developing world.4Open commissurotomy is performed through sternotomy using cardiopulmonary bypass. The surgeon inspects the mitral valve with direct vision, debrides the calcific deposits and separates the fused commissures with the blade. Balloon commissurotomy was first tested by Dr Inoue in the surgical setting in 1982. Transvenous percutaneous balloon commissurotomy was performed for the first time by Dr Inoue in 1984 via transseptal route.5 The mitral valve opening was enlarged by forcing the commissures to split with the inflating balloon, in a manner similar to the …

A 48-year-old woman presented with progressively worsening exertional dyspnoea. Physical examination revealed an accentuated first heart sound, opening snap and holodiastolic mitral murmur. A transthoracic echocardiogram showed severe rheumatic mitral stenosis (valve area: 0.7 cm2; mean pressure gradient: 23 mm Hg; pulmonary artery systolic pressure: 60 mm Hg), mild-to-moderate mitral regurgitation (MR), with a Wilkins score of 7 and valvular anatomy favourable for percutaneous mitral valvuloplasty (PMV). After three successive balloon dilations, the valve area increased to 1.2 cm2, transmitral gradient decreased to 5 mm Hg and mean pulmonary artery pressure to 33 mm Hg. The patient remained stable after the procedure, asymptomatic during hospitalisation, and routine 2D and 3D echocardiography images were obtained before discharge from hospital (figure 1 and online supplementary videos 1 and 2). Figure 1 Two-dimensional (2D) TTE and 2D TEE echocardiographic image …

In cor triatriatum sinister, one of the rarest congenital cardiac anomalies, a membrane divides the left atrium into a pulmonary venous component above and the vestibule below. The importance of the anomaly lies in the effects of the resultant pulmonary venous obstruction that usually present in the first year of life and can mimic obstructed total anomalous venous drainage or congenital mitral stenosis. A case presented as mitral stenosis in the third decade of life, ten years after a well documented episode of Sydenham's chorea. The diagnosis was made rapidly by transthoracic echocardiography and transoesophageal echocardiography was used for complete assessment. Cardiac catheterisation added nothing to the non-invasive diagnosis or the preoperative assessment. Uncomplicated corrective surgery was undertaken.

OBJECTIVE--To determine which factors predict the occurrence of mitral regurgitation after balloon dilatation of the mitral valve for rheumatic stenosis. DESIGN--Analysis of a case series of patients with rheumatic mitral valve stenosis who had had successful balloon dilatation of the mitral valve. SETTING--A tertiary care centre with an experience of over 150 balloon dilatations of the mitral valve. PATIENTS--70 young patients with non-calcified rheumatic mitral stenosis, who had undergone successful balloon dilatation of the mitral valve. No patient had mitral regurgitation or atrial fibrillation before dilatation. INTERVENTION--Dilatation of the mitral valve by the transvenous, transatrial double balloon technique. MAIN OUTCOME MEASURE--Development of mitral regurgitation after balloon dilatation of the mitral valve and its relation to age, mitral valve area before dilatation and after dilatation, the degree of mitral subvalvar pathology, and the size of balloon used for dilatation. RESULTS--In 10 patients (14%) mitral regurgitation developed after balloon dilatation of the mitral valve. No statistically significant differences were found between patients who did not develop regurgitation and those who did in terms of age (mean (SD)) (19.9 (6.46) v 19.4 (5.5)), mitral valve area before dilatation (1.05 (0.33) v 0.94 (0.4) cm2) and after dilatation (2.52 (1.06) v 2.45 (1.1) cm2), mitral subvalvar pathology assessed by the mitral subvalvar distance ratio (0.116 (0.03) v 0.118 (2.32), or balloon diameter corrected for body surface area (21.37 (3.5) v 20.57 (2.32) mm/m2. CONCLUSIONS--In this subset of children and young adults with non-calcified mitral stenosis, none of the morphological, technical, or patient characteristics studied predicted the development of mitral regurgitation after balloon dilatation. The low incidence of mitral regurgitation may have reduced the discriminatory power of this study. None the less, the means and standard deviation for each factor in each group suggest that even in a larger sample size the variables would have little predictive capacity.

To investigate the mechanism that increases the orifice area of the mitral valve during balloon dilatation 43 surgically excised intact rheumatic mitral valves were studied. The main pathological features were (a) fibrosis of mitral valve leaflets and commissures (10 valves); (b) fibrosis with calcification of one commissure (eight anterolateral, seven posteromedial); (c) fibrosis with calcification of both commissures (seven valves); and (d) predominant involvement of the subvalvar apparatus (11 valves). The valves were assessed by photography and radiography before and after balloon dilatation (balloons up to 38 mm (bifoil 2 x 19 mm) and pressures up to 4 atmospheres). The valve was dilated in stages under direct visual control by balloons of increasing diameter. Splitting of the fused commissures was the most common mode of widening the orifice. However, the mitral valve leaflets were torn in two fibrotic valves and in six valves with extensive involvement of the subvalvar apparatus. In the fibrotic valves (group (a] the tear originated near the valve perimeter, at the thinnest part of the remaining valve leaflet. In the valves with subvalvar involvement splitting started at the apex of spaces between the fused chordal columns and proceeded upward. Where there is extensive involvement of the subvalvar apparatus in rheumatic mitral valve disease the risk of tearing of the valve leaflets by balloon dilatation is increased and this is likely to predispose to the development of acute valvar insufficiency.

Objectives To evaluate the interventional therapeutic strategy and effect of one-stage interventional therapy of 109 patients’ with combined congenital heart disease. Methods From June 2000 to October 2012, 109 cases with combined congenital heart disease underwent one-stage interventional therapy. There are 38 males and 71 females ranging from 1 to 56 years old (13.8 ± 14.6). All patients had been diagnosed by X-ray, ECG, echocardiogram, right heart catheterization and cardiac angiography before the interventional therapy. There were 12 cases with Atrial septal defect (ASD) and patent ductus arteriosus (PDA), 39 cases with ASD and pulmonary valvular stenosis (PS), 25 cases with ASD and ventricular septal defect, 1 case with ASD and mitral valve stenosis (MS), 23 cases with VSD and PDA, 8 cases with PDA and PS, 1 case with ASD and PDA and PS. The interventional therapeutic sequence was percutaneous balloon pulmonary valvuloplasty (PBPV) or percutaneous balloon mitral valvuloplasty, VSD closure, PDA closure, ASD closure in turn. And to evaluate the therapeutic effect by echocardiogram, cardiac angiography or cardiac chamber piezometry after procedure immediately. All patients were enforced X-ray, ECG, echocardiogram on 2d, 1, 3 and 6 months after operation for the follow-up. Results All patients were treated successfully. No complications occurred during the procedure. No residual shunt and dislocation of the devices were found. In the patients with PS, the systolic gradient pressure across the pulmonary valve decreased meet a criterion after operation. In 1 case with ASD and mitral valve, the mitral valve orifice areas increased markably after procedure. During the period of follow-up, the enlarged chambers heart were diminished progressively and all the occluders fixed well, X-ray examination showed that pulmonary vascularity diminished significantly, and there was no severe complication in all patients by echocardiogram. Conclusions Though the operation is more difficult and the interventional technic is more skillful, but multiple transcatheter interventions in the same session are feasible, safe and effective with satisfactory good results. However, a satisfactory result can be obtained from suitable indications by TTE before operation, proper algorithm of procedures and standardised manipulations.

Objectives I. Clinical data The patient was a 49-year-old female who presented with complaints of recurrent chest discomfort and serious jaw pain for 7 days. The ECG of the patient made in local hospital showed that the ST-segments were camponotus-like elevation in V2-V6 leads. Then, she was diagnosed as acute anterior wall myocardial infarction and given intravenous thrombolytic therapy with urokinase. The discomfort of chest pain and chest tightness was disappeared 1 h later. The ECG and myocardial enzyme were consistent with the dynamic changes of acute myocardial infarction. The patient had no history of hypertension, coronary heart disease, hyperlipidaemia, diabetes and no family history of premature cardiovascular disease. In recent 3 years, the sick often felt dyspnoea when she was doing hard work. Physical examination showed BP was 126/72 mm Hg and the heart rate was 66/min with a fairly regular rhythm. ECG showed poor R wave progression and abnormal ST-T in lead V3-V6. The echocardiography showed that the sick were rheumatic heart disease with moderate mitral valve stenosis, left atrium thrombus, and weak anterior wall movement. Coronary artery angiography was normal. According to the medical history, we gave the following diagnosis: (1) Acute extensive anterior myocardial infarction (the possible reason was that the falling off of thrombus in left atrium caused anterior descending artery embolism and it became clear after a intravenous thrombolysis); (2) Rheumatic heart disease with moderate mitral valve stenosis and left atrium thrombus. We considered the acute extensive anterior myocardial infarction had nothing to do with coronary atherosclerosis, so we did not use anti-platelet and hypolipidemic drugs, only gave anticoagulant therapy with warfarin when leaving hospital. The echocardiography 3 months later showed that the thrombosis in left atrium was disappeared. The patient was performed replacement of mitral valve successfully in cardiac surgery in December 2011. Now she felt well and keep taking warfarin all the time. Methods The most of myocardial infarctions are caused by broken of unstable plaque in coronary artery and some are related with the serious spasm of coronary artery. The rest are caused by some rare reasons such as coronary embolism, injury, deformity or inflammation. Results The patient had not yet entered menopause and had on traditional risk factors of coronary heart disease such as high blood-fat, blood-pressure, diabetes, smoking, fatness, hyperhomocysteinemia and premature cardiovascular disease family history. In the whole process of the disease there were typical ischaemic chest pain and the dynamic evolution of ECG and myocardial enzyme which were in accord with the change of the myocardial infarction. Conclusions The patient was diagnosed as acute extensive anterior myocardial infarction finally. Considered the coronary angiography of the patient was normal, we summarised that the myocardial infarction was likely caused by break off of the thrombus which brought embolism of left anterior descending arterial and disappeared after intravenous thrombolysis.

Case Study Clinical Data Patient: Male, 52 years old, because of exertional chest tightness, dyspnea and fatigue for 3 years, aggravated half a months, admitted to hospital on August 28, 2010: blood pressure 120/75 mm Hg, the apex beat was located at outside 2 cm of left space midclavicular line, in the sixth intercostal space, right sternal border of the second intercostal space had thrill, heart border was to bottom left expansion. The heart rate was 112 bpm, cardiac tone of irregular force, and heart rhythm was absolutely irregular. There had IV/6 systolic murmur at right sternal border of the second intercostal space, conducted to the neck, mezzo diastolic murmur could be heard at apex of heart. By echocardiography tips: rheumatic heart disease with aortic stenosis (moderate), mitral valve stenosis (moderate), left atrioventricular enlargement. Left ventricular had diastolic dysfunction, but systolic function was normal. This patient did coronary angiography before surgical valve replacement. The coronary angiography results: both mitral valve and aortic valve were significant calcification. Left coronary artery angiography tips: the left main artery, left anterior descending (LAD) artery and circumflex branch artery were normal distribution, and no calcification and stenosis, blood flow was TIMI 3 level (figure 1 and figure 2), left main blood pressure was 95/65 mm Hg (mean 81 mm Hg). The right coronary angiography Tips: the right main artery and branches were normal distribution, and no calcification and stenosis, blood flow was TIMI 3 level (figure 3), right coronary artery opening blood pressure was 130/80 (mean 102 mm Hg). But we could see collateral circulation from the distal segment of right coronary artery ahead to distal segment of LAD, the distal artery of LAD and its branches were clearly developed, up to rantrop II level flow. Analysed the data of the left coronary artery angiography again, both left main coronary artery and LAD had no stenosis in proximal and middle artery.

Balloon mitral valvuloplasty has, over the last 15 years, become an established interventional procedure. For patients with pliable uncalcified mitral stenosis, dilatation with the Inoue balloon is the intervention of choice, offering results comparable to surgical commissurotomy.1 In the Western world, however, with the gradual extinction of rheumatic fever, patients with mitral stenosis are now almost exclusively elderly. Such patients tend to have calcified, thickened, and relatively immobile valves, often with significant subvalvar disease, and as such are theoretically unsuited to balloon valvuloplasty.2 3 But even a small increase in mitral valve orifice may be adequate to allow an elderly person to regain their independence; therefore some have advocated undertaking the interventional option at low risk, with only moderate expectations, rather than opting for mitral valve replacement, with its significant perioperative morbidity and mortality. But is this approach justified? In this issue of Heart , Sutaria and colleagues describe long term outcome for elderly patients undergoing balloon valvuloplasty at one high volume UK centre.4Patients considered unsuitable for surgery—in whom the decision to offer valvuloplasty was therefore in some respects straightforward—had a relatively poor, though not surprising, event free survival rate of 25% at five years. Among those considered suitable for surgical treatment, one year survival free of death or mitral valve replacement, and with improvement in New York Heart Association class by at least one grade, was 64%, falling to 36% at five years. By this stage, numbers were few. In the absence of a randomised trial of surgical versus interventional management of mitral stenosis in elderly patients (which is never likely to happen, and in which treatment arms could not be strictly comparable anyway5), mitral valvuloplasty would seem on this evidence to be a …