Comparison of early results of percutaneous metallic mitral commissurotome with Inoue balloon technique in patients with high mitral echocardiographic scores

Comparison of early and long-term follow-up results of percutaneous mitral balloon valvuloplasty and mitral valve replacement

BACKGROUND

Percutaneous mitral balloon valvuloplasty and mitral valve replacement have been the treatment options for mitral stenosis for several years, however, studies that compare these two modalities are very rare in the literature.

OBJECTIVE

In this article, we aim to investigate the comparison of clinical results of percutaneous mitral balloon valvuloplasty and mitral valve replacement.

METHODS

527 patients with rheumatic mitral stenosis, treated with percutaneous mitral balloon valvuloplasty or mitral valve replacement (276 patients with percutaneous mitral balloon valvuloplasty and 251 patients with mitral valve replacement) from 1991 to 2012 were evaluated. The demographic characteristics, clinical, echocardiographic and catheterization data of patients were evaluated retrospectively. The results of early and late clinical follow-up of patients after percutaneous mitral balloon valvuloplasty and mitral valve replacement were also evaluated.

RESULTS

The mean follow-up time of the percutaneous mitral balloon valvuloplasty group was 4.7 years and, for the mitral valve replacement-group, it was 5.45 years. The hospital stay of the percutaneous mitral balloon valvuloplasty group was shorter than that of the mitral valve replacement group (2.02 days vs 10.62 days, p<0.001). The hospital mortality rate of percutaneous mitral balloon valvuloplasty and mitral valve replacement were 0% and 2% respectively (p=0.024). In the percutaneous mitral balloon valvuloplasty group, early postprocedural success rate was 92.1%. The event-free survival of percutaneous mitral balloon valvuloplasty and mitral valve replacement was found to be similar. While reintervention was higher in percutaneous mitral balloon valvuloplasty-group (p<0.001), mortality rate was higher in mitral valve replacement-group (p<0.001).

CONCLUSION

Percutaneous mitral balloon valvuloplasty seems to be more advantageous than mitral valve replacement due to low mortality rates, easy application of the procedure and no need for general anesthesia.

Predictors of developing significant mitral regurgitation following percutaneous mitral commissurotomy with inoue balloon technique

Background. Despite the high technical expertise in percutaneous mitral commissurotomy (PMC), mitral regurgitation (MR) remains a major procedure-related complication. The aim of this work is to find out the most sensitive and applicable predictors of development of significant mitral regurgitation (SMR) following percutaneous mitral commissurotomy using Inoue balloon technique. Methods. We studied prospectively the preprocedural (clinical, echocardiography, and hemodynamic) and procedural predictors of significant mitral regurgitation (identified as increase of ≥2/4 grades of pre-PMC MR by color Doppler flow mapping) following valvuloplasty using Inoue balloon in 108 consecutive patients with severe mitral stenosis. Multiple stepwise logistic regression analysis was performed for variables found positive on univariate analysis to determine the most important predictor(s) of developing SMR. Results. The incidence of SMR following PMC using Inoue technique was 18.5% (10 patients). MV scoring systems were the only variables that showed significant differences between both groups (Group A without SMR and Group B with SMR). However, no clinical, other echocardiographic measurements, hemodynamic or procedural variables could predict the development of SMR. Using multiple regression analysis, the best predictive factor for the risk of SMR after Inoue BMV was the total MR-echo score with a cutoff point of 7 and a predictive percentage of 97.7%. Conclusions. The total MR-echo score is the only independent predictor of SMR following PMC using Inoue technique with a cutoff point of 7.

Epidemiology and prevention of valvular heart diseases and infective endocarditis in Africa

Valvular heart diseases in Africa affect mainly children and young adults and are a result of rheumatic fever. Rheumatic fever is a preventable disease, but in Africa the combination of a lack of resources, lack of infrastructure, political, social and economic instability, poverty, overcrowding, malnutrition and lack of political will contributes to the persistence of a high burden of rheumatic fever, rheumatic valvular heart diseases and infective endocarditis. Combating and eradicating rheumatic fever and rheumatic heart diseases requires economic development and implementation of best practices of primary and secondary prevention measures. The barriers to achieving this goal in Africa are numerous, but not insurmountable.

The clinical and hemodynamic results of mitral balloon valvuloplasty for patients with mitral stenosis complicated by severe pulmonary hypertension

BACKGROUND

Percutaneous balloon mitral valvuloplasty (PBMV) has become the procedure of choice for isolated, uncomplicated mitral stenosis (MS) with favorable morphology and may be a useful method for surgical high-risk conditions such as advanced age, the presence of severe tricuspid regurgitation, New York Heart Association (NYHA) class IV at presentation, and severe pulmonary hypertension (PH). The development of PH is a common and important sequela in patients with advanced mitral stenosis and is associated with hemodynamic and clinical decompensation. However, the influence of PBMV on patients with severe PH has seldom been evaluated. Our objective was to probe into the immediate and long-term effects of PBMV on patients with MS complicated by severe PH and to predict the factors that determine the prognosis of patients with severe PH.

METHODS

We included 44 patients with MS complicated by severe PH (systolic pulmonary pressure >80 mm Hg, group S) and 67 patients with MS complicated by mild PH (systolic pulmonary pressure <50 mm Hg, group M) in this study and we compared their immediate and late results after a follow-up period of 24 months after PBMV.

RESULTS

Compared with group M, patients in group S were older, presented more frequently with NYHA III-IV class, valvular echo score >or=8, and more severe tricuspid regurgitation, and had a bigger left atrial diameter before PBMV. The successful rate and the incidence of severe complications from the PBMV procedure were similar in both groups. There were more cases of post-PBMV mitral valve area >or=1.5 cm(2) in group M than in group S, and the average mitral valve area in group M was somewhat larger than that of group S. After PBMV, NYHA class obviously improved in both groups, but there were more patients with NYHA<or=class II in group M than in group S at discharge. During the 24-month follow-up, 7 patients (10.5%) in group M and 11 (25.0%) in group S developed cardiac events (p<0.1). Cumulative event-free survival was 89.6% in group M and 75.0% in group S (p>0.05). NYHA class I or II was present for 80.6% in group M and 59.1% in group S (p<0.10).

RESULTS

PBMV is a safe and effective procedure for patients with severe PH. It can remarkably improve clinical outcomes, although hemodynamic effects of PBMV on this subgroup are not complete. Pre-existing older age, more severe valvular lesion and tricuspid regurgitation, worse cardiac function, and bigger left atrial size in patients with severe PH may be important risk factors for the poor hemodynamic outcomes of PBMV.

Randomized comparison between Inoue balloon and metallic commissurotome in the treatment of rheumatic mitral stenosis: immediate results and 6-month and 3-year follow-up

The metallic commissurotome (MC) technique is a cheaper alternative to the Inoue balloon (IB) technique for percutaneous mitral valvuloplasty (PMV). There are no randomized trials comparing these techniques with longer follow-up of the patients. The objective of this study was to compare the immediate results and short- and medium-term follow-up of PMV using either the IB or the MC technique. Fifty patients with rheumatic mitral stenosis were randomly assigned to PMV using the IB (n = 27) or the MC (n = 23) technique. There were no significant differences between the groups regarding baseline clinical, echocardiographic, and hemodynamic data. Clinical and echocardiographic follow-up were done 6 months and 3 years after the procedure. The success rate was 100% in the IB group and 91.3% in the MC group (P = 0.15); two patients in the latter group developed mitral regurgitation grade 3/4, requiring elective surgery. The mean final mitral valve area was bigger in the MC group (2.17 +/- 0.13 vs. 2.00 +/- 0.36 cm2; P = 0.04), but after 6-month and 3-year follow-up, this difference was no longer significant (2.06 +/- 0.27 vs. 1.98 +/- 0.38 cm2, P = 0.22, and 1.86 +/- 0.32 vs. 1.87 +/- 0.34 cm2, P = 0.89, respectively). This finding suggests valve stretching as an important mechanism of valve dilation with the MC. Three patients in the MC group and two patients in the IB group (P = 0.65) developed mitral valve restenosis; one of them underwent repeat PMV and the other four, all asymptomatic, were clinically followed. PMV performed either with the IB or the MC technique is effective and provides excellent short- and medium-term outcomes regardless of the technique employed.