Search

Background: Scoring of mitral stenosis (MS) severity is very important for selection of patients for balloon mitral valvuloplasty (BMV)., Objective: We propose a novel yet simple, independent parameter of MS severity based on the posterior mitral valve leaflet to anterior mitral valve leaflet length ratio (PMVL/AMVL length ratio). It could be a useful predictor to outcome of BMV., Subjects and Methods: A total of 106 patients (mean age 29.1 ± 8.6 years) had MS with mitral valve score of eight or less. The length of anterior mitral valve leaflet and posterior mitral valve leaflet were measured. Patients were classified into group with ratio ≥1/2 and group of ratio <1/2. Eighty-five healthy control subjects were studied., Results: Patients with PMVL/AMVL ratio ≥1/2 post-BMV had lower transmitral gradients (4.5 ± 3.1 mmHg vs. 9.7 ± 2.1 mmHg, P < 0.002) and greater mitral valve area (MVA) (2.09 ± 0.3 cm(2) vs. 1.5 ± 0.2 cm(2) , P < 0.001), lower pulmonary artery systolic pressure (PASP) (23.8 ± 14.3 mmHg vs. 34.2 ± 12.5 mmHg, P < 0.001), left atrial pressure (10.2 ± 6.7 mmHg vs. 18.9 ± 6.4 mmHg, P < 0.001), and lower incidence of de novo or worsening of mild mitral regurgitation (MR; 1.64% vs. 8.9%, 0% vs. 6.6%, P < 0.001). PMVL/AMVL length ratio was positively correlated with post-BMV MVA (r = 0.69, P < 0.002), PASP (r = 0.592, P < 0.003), and negatively correlated with incidence of de novo or worsening of mild MR (r =-0.78, -0.93, P < 0.001). The regression analyses revealed that PMVL/AMVL ratio is the best and a reliable predictor of success and outcome of BMV, hazard ratio (95% confidence interval) 0.12 (0.05-52), P < 0.001., Conclusion: Length ratio of PMVL/AMVL assessment with echocardiography is an excellent simple predictor of post-BMV mitral valve area and the cardiac events., (© 2011, Wiley Periodicals, Inc.)

Objective: Percutaneous mitral balloon valvuloplasty (PMBV) is the method of choice in treatment of patients with hemodynamically significant mitral stenosis. We aimed to analyze acute and long-term clinical and echocardiographic consequences of PMBV., Methods: In this retrospective cohort study; 311 patients who underwent PMBV in our Cardiology Clinic at Türkiye Yüksek İhtisas Education and Research Hospital between January 2000 and March 2004 were evaluated for acute procedural outcomes and primary endpoints (death, rePMBV, mitral valve replacement (MVR)). All 311 patients were contacted by phone call or letter at least five years after the procedure. Of the 311 patients, 87 who defined NYHA class II-IV symptoms were invited for a control visit and detailed echocardiographic evaluation. Sixty-three patients out of 87 who completed follow-up were enrolled for long-term consequences. Those 63 patients were subclassified into two groups as those without any negative event (n=26) (Group 1) and those with mitral valve area (MVA) (<1.5 cm(2)), rePMBV or referral to MVR (n=37) (Group 2) on follow up to 6.4±1.6 years., Results: In the analysis of 311 patients, acute post procedural success, which was defined as mitral valve area (MVA) ≥1.5 cm(2) without severe mitral regurgitation, was 94% and was only associated with preprocedural MVA (p=0.008). In the logistic regression analysis, preprocedural MVA was the only independent parameter, associated with acute procedural success (Expβ=0.004, 95%CI 0.0001-0.234, p=0.008). In the long-term follow up of 63 patients, the patients with uneventful course (Group 1) had significantly higher MVA (p<0.001), lower mean (p=0.001) and peak (p<0.001) transmitral gradients immediately after the procedure when we compared to the patients in Group 2. It was also noticed that patients with at least 60% improvement in MVA experienced composite end point much less frequently compared to those with less than 60% improvement in MVA (5% vs. 30.4%, p=0.009). Kaplan-Meier analysis yielded significantly diverging cumulative survival curves for those with and without at least 60% improvement in MVA (p=0.003)., Conclusion: Concerning long-term follow up data of patients undergoing PMBV in a single center, it seems only acute postprocedural MVA was significantly associated with long-term consequences.

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

Background: Percutaneous mitral valvuloplasty (PMV) is a minimally invasive treatment option for selected patients with mitral stenosis (MS). In general, the procedure is well-tolerated with a high success rate. However, relatively little is known about the predictors of surgical intervention after PMV., Methods: A retrospective analysis was performed on 243 patients undergoing PMV at a single institution over a 14 year period., Results: Fifty (21%) of 243 patients, comprising 44 women and 6 men and aged 55 +/- 14 years, underwent cardiac surgery at a median interval of 6 months (range, 0 to 130) after PMV. Nine (18%) underwent a procedure within 15 days, and 41 (82%) had a procedure more than 15 days after the valvuloplasty. After PMV, surgery-free survival was 85% at 1 year, 83% at 2 years, 81% at 3 years, 80% at 4 years, and 80% at 5 years., Conclusions: The need for surgery after PMV is not uncommon. Independent predictors of surgery after PMV included severity of mitral regurgitation (p < 0.003) and a higher echo score (p < 0.039).

The long-term results of percutaneous mitral commissurotomy were evaluated in 606 patients with a mean age of 48 +/- 14 years. One hundred and eleven patients (48%) had a history of surgical commissurotomy. At echocardiography, 91 patients (15%) had flexible leaflets and little subvalvular apparatus, and 180 (30%) have calcified valves. The procedure was performed with a single balloon in 21 patients, a double balloon in 402 patients and Inoue's balloon in 183 patients. A good immediate, result, defined as a mitral valve surface area > or = 1.5 cm2 without > 2/4 mitral regurgitation, was obtained in 528 patients (87%). Five hundred and eighty patients (96%) were followed up for an average of 30 +/- 18 months. The actuarial 5 year rates were: survival 94 +/- 4%; survival without surgery 74 +/- 6%; survival without surgery with a good functional result (NYHA Classe I and II) 66% +/- 6%. Factors predictive of a good functional result were the valvular anatomy (p = 0.01), the NYHA Class before the procedure (p = 0.02), the cardiothoracic ratio before the procedure (p = 0.005) and mitral valve surface area after the procedure (p = 0.007). The type of balloon had no influence on the result (p = 0.54). The authors conclude that the 5 year results of percutaneous mitral commissurotomy are good in a population of patients with varied characteristics. The persistence of good functional results depends on anatomical and functional data and the quality of the initial result, but not on variables related to the procedure.

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.

Objectives: This study sought to assess late functional results after successful percutaneous mitral commissurotomy and to determine their predictors., Background: Few studies have reported late results of percutaneous mitral commissurotomy or have analyzed their late results regardless of immediate results, despite the fact that late deterioration may well be related either to a decrease in valve area or to poor initial results., Methods: Between 1986 and 1992, 528 patients underwent successful percutaneous mitral commissurotomy (mean [+/- SD] age 46 +/- 18 years; mean follow-up 32 +/- 18 months). A successful procedure was defined by a mitral valve area > or = 1.5 cm2 and no regurgitation > 2/4. Dilation was performed using a single balloon in 13 patients, a double balloon in 349 and the Inoue balloon in 166. Multivariate analysis was performed with a Cox model., Results: The survival rate for patients in New York Heart Association functional class I or II, with no cardiac-related deaths or need for mitral surgery or repeat dilation, was 76 +/- 6% at 5 years. By multivariate analysis, the independent predictors of good functional results were echocardiographic group (p = 0.01), functional class (p = 0.02) and cardiothoracic index (p = 0.005) before the procedure and valve area after the procedure (p = 0.007). The predictive model derived allowed estimation of the probability of good functional results according to the value of these four predictors for any given patient., Conclusions: Good functional results were observed 5 years after successful percutaneous mitral commissurotomy in a large series of varied patients. The analysis of predictive factors may provide useful indications for follow-up results in patients undergoing this technique.

Percutaneous transvenous mitral commissurotomy using the Inoue technique was performed in 390 cases of rheumatic mitral stenosis. There were 220 (56%) females and 170 (44%) males. The age range was 9-47 years [mean +/- S.D., 26 +/- 14) and all were symptomatic (New York Heart Association (NYHA) class II in 23 (6%); class III in 280 (72%); and class IV in 87 (22%) patients]. Mitral valve area increased from 0.6 +/- 0.4 to 2 +/- 0.7 cm2, mean transmitral gradients decreased from 26 +/- 8 to 5 +/- 3 mmHg and cardiac index improved from 2.2 +/- 0.8 to 3.0 +/- 0.7 l/min/m2 (P < 0.001). There were no procedure related deaths. An increase in mitral regurgitation by one grade was observed in 40 (10%) cases, with 8 (2%) cases developing severe mitral regurgitation. Oximetry evidence of left to right atrial shunt (Qp/Qs > or = 1.5:1) was observed in 11 (3%) patients. Four (1.0%) patients developed cardiac tamponade, none had thromboembolism. Follow-up of 290 cases at 26 +/- 5 weeks showed persistent improvement in clinical (NYHA class I in 98%) and echocardiographic mitral valve area. Percutaneous transvenous mitral commissurotomy is safe, easy to perform and provides excellent clinical and hemodynamic benefit in the majority of cases.

Background: Although initial success rates for mitral valve balloon dilatation are currently about 85%, the procedure remains investigational and is not performed in many centers because the procedure is technically challenging and has uncertain long-term results., Aim: The purpose of this report is to identify the predictors of long-term results after mitral valve balloon dilatation., Results: At 30-day follow-up of 738 patients treated at 24 centers (mean age 54 years), 4% of patients required mitral valve surgery, 3% had died, and 83% had their overall condition improved. At 2-month and 1-year follow-up of 17 patients treated at one center, quality of life showed sustained improvement as measured by the Sickness Impact Profile. At 5-year follow-up of 146 patients treated at a single center (mean age 59 years), overall survival was 76% and event-free survival was 51%. At 5-year follow-up of a younger group of 350 patients (mean age 46 years), overall survival was 94% and event-free survival was 85%. Predictors of survival after mitral balloon dilatation included age and baseline New York Heart Association functional class. Predictors of restenosis included the presence of valve calcification and leaflet thickening., Conclusions: Mitral valve balloon dilatation has good long-term outcome for selected patients with mitral stenosis. The long-term outcome after this procedure can be predicted from baseline clinical and valvular characteristics.

Despite the introduction of penicillin and improvements in the standard of living and delivery of primary health care, rheumatic mitral stenosis remains an important medical problem in the United States as well as abroad. In the past decade, percutaneous transvenous mitral commissurotomy (PTMC) with the Inoue balloon catheter has emerged as a safe and efficient treatment for symptomatic patients and has supplanted surgical commissurotomy as the initial treatment approach in the majority of patients with mitral stenosis. Acutely, balloon valvuloplasty can achieve an approximately 100% increase in mitral valve area and markedly improve symptoms, including dyspnea and NYHA functional class. However, peak oxygen consumption during exercise may not increase acutely, and the subjective improvement in dyspnea is likely related to a diminished work of breathing. Chronically, the hemodynamic improvements achieved with PTMC are maintained (up to 5 yr) with a low rate of recurrent symptoms due to restenosis, production, or progression of mitral regurgitation or inadequate initial dilation. Freedom from death, mitral valve replacement, and repeat valvuloplasty range between 51% and 84% at 4-5 yr postprocedure, depending on various selection criteria. Functional improvement, as measured by exercise capacity with respiratory gas analysis, occurs over several months suggesting that chronic peripheral alterations in the skeletal muscle and vasculature of patients with long-standing mitral stenosis may limit the initial benefit of successful PTMC until vascular remodeling or aerobic training can allow the skeletal musculature to use the greater cardiac output afforded by successful PTMC. Careful patient selection is essential to obtain the best hemodynamic improvement with the lowest rate of complications.(ABSTRACT TRUNCATED AT 250 WORDS)

The Inoue balloon was first used for percutaneous transvenous mitral commissurotomy in 1982 and was commercialized 5 yr later. The experience obtained in thousands of cases performed throughout the world show: (1) the stepwise dilatation technique under echocardiographic guidance appears to be the most efficient and allows the most to be made of this balloon's inherent possibilities, (2) in comparison with other balloon techniques, the advantages of the Inoue balloon are that it is simpler to use, provides equivalent improvement in valve area, and has lower risks, particularly in relation to the production of mitral regurgitation, and (3) long-term results appear similar to those provided by other balloon techniques. Inoue's technique is currently the most widely used for mitral valvuloplasty in the world. Its further development and use depend on further studies of its long-term results together with improvement in the economic aspects.

The aim of this study was to assess the initial and midterm outcome of patients with severe pulmonary hypertension undergoing percutaneous mitral valvuloplasty (PMV). Accordingly, the baseline characteristics, immediate results and follow-up of 64 consecutive patients with severe pulmonary artery hypertension (systolic pulmonary artery pressure > or = 60 mm Hg on cardiac catheterization) (group I) were analyzed and compared with those of 194 consecutive patients with lower pulmonary pressures (group II). Patients in group I were more symptomatic (New York Heart Association functional class > or = III, 72 vs 40%, p < 0.001) and had higher echocardiographic scores (8.6 +/- 2 vs 7.4 +/- 1, p < 0.05). Before PMV, mitral gradient was higher (17 +/- 6 vs 13 +/- 5 mm Hg, p < 0.025) and mitral valve area smaller (0.79 +/- 0.2 vs 0.96 +/- 0.2 cm2, p < 0.005) in group I patients, who also had higher pulmonary vascular resistances (469 +/- 299 vs 157 +/- 125 dynes s-1 cm-5, p < 0.005). On multivariate analysis patients in group I were more symptomatic, had smaller mitral valve areas and higher mitral gradients. PMV success (area gain > 50% without complications) was similar (89 vs 87%) in both groups. After PMV final mitral gradient (5 +/- 2 vs 4 +/- 2 mm Hg) and area (1.82 +/- 0.5 vs 1.87 +/- 0.5 cm2) were similar in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

In 110 adult selected patients, 87.1% female (average age 38.2 years, range 16-72) with symptomatic, severe mitral stenosis eligible for surgery, we performed balloon catheter transvenous mitral commissurotomy (BCTMC) as alternative treatment. Inoue's catheter was utilized in 80 cases (72.7%), and the double-balloon technique in 30 (27.3%). The procedure was successful in 102 patients (92.7%, 2nd attempt in 5 cases), with optimal results in 96 (87.3%); and it was unsuccessful in one patient for a technical difficulty. Complications occurred in 3 cases due to perforation of a cardiac chamber (2.7%); and 4/106 patients developed severe mitral insufficiency (3.8%). The mitral valve area increased from 1.09 +/- 0.27 to 2.6 +/- 0.87 cm2 (p < 0.0001); the diastolic mitral gradient decreased from 18.9 +/- 5.9 to 3.6 +/- 2.8 mmHg (p < 0.0001); similar reduction was obtained in mean left atrial pressure from 26.2 +/- 6.5 to 12.5 +/- 4.2 mmHg (p < 0.0001), and mean pulmonary artery pressure from 38 +/- 17 to 26.2 +/- 10.4 mmHg (p < 0.005). New mitral insufficiency appeared or increased in more of one grade in 12/106 patients (11.3%), and it was not detectable in 86/106 patients. During long-term follow-up (average 10.4 months, range 5 to 24), all patients (100 cases) improved their functional class (83.1% asymptomatic), and maintained their 2D echocardiographic mitral valve area. In conclusion BCMTC is the treatment of choice for selected cases of acquired symptomatic mitral stenosis, with immediate and long term results comparable to surgical commissurotomy.

Since May 1991 to July 1992, 83 patients (mean age 49 +/- 13 years, 17 males and 66 females) underwent percutaneous mitral valvuloplasty according to Inoue's technique. Following Wilkins' criteria echo-score was < or = 8 in 46 patients and mono-commissural calcifications were present in 8 cases. Sixteen (19%) patients had previous surgical mitral commissurotomy and 15 (18%) had previous embolic events. The indications for the procedure were given on the basis of the echo-score (ideal cases with score < or = 8). All patients but 2 were successfully treated. Two patients who developed mitral regurgitation grade 3+/4+ were referred to elective surgery. Mitral valve area increased from 1.1 +/- 0.2 to 2 +/- 0.3 cm2 (p < 0.001) and transvalvular pressure gradient fell from 16 +/- 5 to 6 +/- 3 mmHg (p < 0.001). Patients with previous surgical commissurotomy had a lower increase in mitral valve area than patients without previous surgery (p < 0.02). Patients with echo-score > 8 presented a more evident increase in mitral regurgitation than patients with good valvular anatomy, even if this difference was not significant. At 6 and 12 month follow-up respectively 2 and 1 restenosis occurred, but in 1 of these cases the residual valvular area was > 1.5 cm2. The authors conclude that in selected patients with mitral stenosis percutaneous mitral valvuloplasty seems to be an effective and safe treatment. Furthermore, immediate and middle-term results show that this technique can be performed without adjunctive risks and with satisfactory results also in cases of no ideal clinical and/or valvular conditions (echo-score > 8, previous surgical commissurotomy, history of embolism, mono-commissural calcifications).

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.

Objectives: The primary hypothesis examined was that underfilling due to inflow obstruction accounts for modestly depressed ejection performance in mitral stenosis. Having found little evidence to support this hypothesis, we sought to determine other factors that might differentiate patients with different levels of ejection performance., Methods: Ventricular load and performance were compared in two groups of patients before and immediately after successful balloon valvuloplasty that was not complicated by mitral regurgitation: those in whom prevalvuloplasty ejection fraction was > or = 0.55 (group I, n = 10) and those in whom it was < 0.55 (group II, n = 11)., Results: Before valvuloplasty, mitral valve area was less in group II (0.65 cm2) than in group I (0.84 cm2, p = 0.02), but end-diastolic pressure (12 vs. 12 mm Hg in group I), end-diastolic wall stress (46 vs. 44 kdynes/cm2 in group I) and end-diastolic volume (152 vs. 150 ml in group I) were not less in group II, nor were these variables significantly reduced compared with those of a normal control group. In group II, end-systolic volume was larger (77 vs. 55 ml in group I, p = 0.001) and cardiac output was less (3.1 vs. 3.6 liters/min in group I, p = 0.03), possibly owing to higher systemic vascular resistance (2,438 vs. 1,921 dynes.s.cm-5 in group I, p = 0.05) and end-systolic wall stress (273 vs. 226 kdynes/cm2 in group I, p = 0.06), although mean arterial pressure in the two groups was similar (91 vs. 84 mm Hg in group I, p = 0.22). Group II patients also had higher values for pulmonary vascular resistance (712 vs. 269 dynes.s.cm-5 in group I, p = 0.03) and mean pulmonary artery pressure (47 vs. 29 mm Hg in group I, p = 0.02) despite similar values for mean left atrial pressure (20 vs. 18 mm Hg in group I, p = 0.35). After valvuloplasty, mitral valve area increased by 2.5- and 3-fold, respectively, in group I (to 2.1 cm2) and group II (to 2.0 cm2). Modest increases in left ventricular end-diastolic pressure, end-diastolic stress and end-diastolic volume (+9%) after valvuloplasty were statistically significant only for group II. End-systolic wall stress did not decline in either group II (281 kdynes/cm2) or group I (230 kdynes/cm2), and ejection fraction failed to increase significantly (0.49 to 0.51 for group II and 0.62 to 0.61 for group I) after valvuloplasty. Contractile performance estimated with a preload-corrected ejection fraction-afterload relation was within or near normal limits in all 19 patients in whom it was assessed., Conclusions: Excessive vasoconstriction may account for the higher afterload, lower ejection performance and lower cardiac output observed in a subset of patients with mitral stenosis because contractile dysfunction could not be detected and left ventricular filling--which was not subnormal despite severe inflow obstruction--improved only modestly after valvuloplasty.

Background: In response to the increasing use of percutaneous balloon mitral commissurotomy, the National Heart, Lung, and Blood Institute established the Balloon Valvuloplasty Registry in November 1987., Methods and Results: Between November 1, 1987, and October 31, 1989, 738 patients aged 18 or older underwent percutaneous balloon mitral commissurotomy at the clinical sites. Data were prospectively entered into the registry at the time consent was obtained. Serious complications occurred in 87 procedures, or 12%. Death in the laboratory occurred in eight patients, or 1%. Within 30 days there were 24 cumulative deaths, 18 cardiac and six noncardiac. Univariate analysis revealed that older age, a history of cardiac arrest, cerebrovascular disease, dementia, renal insufficiency, cachexia, class IV congestive heart failure, use of an intra-aortic balloon pump, use of sympathomimetic amines, and a high echo score (greater than or equal to 13) were associated with early death (p less than 0.01). Additional univariate predictors included a precommissurotomy mitral valve area of less than 0.7 cm2. Left atrial pressure greater than 12 mm Hg and a mitral valve area of less than 1.5 cm2 after the procedure were also associated with higher 30-day mortality (p less than 0.05). Multivariate analysis identified higher echo score and smaller valve area before the procedure as the strongest predictors of early death (p less than 0.001). Centers that performed more than 25 procedures also had lower complication rates., Conclusions: Although percutaneous balloon mitral commissurotomy appears to be effective at relieving the hemodynamic effects of rheumatic mitral stenosis, it does have risks. In properly selected patients, however, it appears to have low morbidity and 30-day mortality. Individual center experience with the procedure also appears to have great impact on complications.

Percutaneous mitral valvuloplasty is a promising new technique for the treatment of mitral stenosis, with a relatively low complication rate reported to date. To assess the sequelae of this procedure, Doppler echocardiographic studies were prospectively performed before and after percutaneous mitral valvuloplasty in a series of 172 patients (mean age 53 +/- 17 years). After balloon dilation, mitral valve area increased from 0.9 +/- 0.3 to 2 +/- 0.8 cm2 (p less than 0.0001), mean gradient decreased from 16 +/- 6 to 6 +/- 3 mm Hg (p less than 0.0001) and mean left atrial pressure decreased from 24 +/- 7 to 14 +/- 6 mm Hg (p less than 0.0001). Although most patients were symptomatically improved, six (4%) were identified who had unusual sequelae evident on Doppler echocardiographic examination immediately after percutaneous mitral valvuloplasty. These included rupture of a posterior mitral valve leaflet, producing a flail distal leaflet portion with severe mitral regurgitation detected on Doppler color flow mapping (n = 1); asymptomatic rupture of the chordae tendineae attached to the anterior mitral valve leaflet with systolic anterior motion of the ruptured chordae into the left ventricular outflow tract (n = 1); a double-orifice mitral valve (n = 1); and evidence of a tear in the anterior mitral valve leaflet (n = 3), producing on both pulsed Doppler ultrasound and color flow mapping a second discrete jet of mitral regurgitation in addition to regurgitation through the main mitral valve orifice. All six patients made a satisfactory recovery and none has required mitral valve replacement.(ABSTRACT TRUNCATED AT 250 WORDS)

A 26-year-old woman with severe pliable mitral stenosis underwent successful balloon mitral valvuloplasty at the end of the second trimester of pregnancy. The indication for intervention was severe shortness of breath during most daily activities, despite combined beta-blocker and diuretic treatment (FC III, NYHA). After use of a 2 x 19 bifoil balloon there was significant clinical and hemodynamic improvement. Shortness of breath disappeared, the mean mitral valve diastolic gradient decreased from 24 to 7 mmHg and the mitral valve area increased from 0.8 to 1.8 cm. There were no complications of the treatment, and estimated radiation exposure of the fetus was less than 0.2 rad. Subsequent abdominal ultrasound examination revealed normal fetal functioning. 2.5 months after mitral dilatation delivery was normal. Balloon mitral valvuloplasty may safely be used instead of surgery as a palliative procedure for relief of symptoms in pregnant women with severe pliable mitral stenosis.

Since its introduction as an alternative to surgical commissurotomy, percutaneous mitral valvuloplasty (PMV) has been performed in a large number of patients with mitral valve stenosis. PMV significantly improves valvular function, the final increase in mitral valve area being about 2 sq cm. The quality of the results obtained is principally related to the anatomy of the valve. The overall incidence of complications is low. The mortality rate ranges from 0.5 to 4 p. 100 in severe mitral stenosis. Left-to-right atrial shunting is detected by oximetry in 20 p. 100 of the cases, but it subsequently disappears in two thirds of the patients; late results are only known at medium term. When the initial result is satisfactory functional improvement is the rule and the incidence of restenosis is low. When the initial result is insufficient, or when mitral stenosis develops open heart surgery is usually necessary. The decision to perform PMV should only be made after exclusion of its contraindications: left atrial thrombosis, moderate to severe mitral stenosis. Because of the encouraging results obtained, PMV can be envisaged as first choice treatment of mitral stenosis with flexible cusps. In calcified mitral stenosis the standard treatment is mitral valve replacement, PMV being reserved to some particular cases.