Repeat percutaneous balloon mitral valvotomy vs. mitral valve replacement in patients with restenosis after previous balloon mitral valvotomy and unfavorable valve characteristics

The 40th Anniversary of Percutaneous Balloon Valvuloplasty for Mitral Stenosis: Current Status

Percutaneous balloon mitral valvuloplasty (PBMV), once the most complex of percutaneous cardiac procedures and essentially the first adult structural heart intervention, set the stage for a host of new technologies. Randomized studies comparing PBMV to surgery were the first to provide a high-level evidence base in structural heart. The devices used have changed little in 40 years, but the advent of improved imaging and the expertise gained in interventional cardiology has provided some additional procedural safety. However, with the decline in rheumatic heart disease, PBMV is being performed in fewer patients in industrialized nations; in turn, these patients have more comorbidities, less favorable anatomy, and thus a higher rate of procedure-related complications. There remain relatively few experienced operators, and the procedure is distinct enough from the rest of the structural heart intervention world that it has its own steep learning curve. This article reviews the use of PBMV in a variety of clinical settings, the influence of anatomic and physiologic factors on outcomes, the changes in the guidelines, and alternative approaches. PBMV remains the procedure of choice in patients with mitral stenosis with ideal anatomy and a useful tool in patients with less than ideal anatomy who are poor surgical candidates. In the 40 years since its first performance, PBMV has revolutionized the care of mitral stenosis patients in developing countries and remains an important option for suitable patients in industrialized nations.

Rheumatic heart disease anno 2020: Impacts of gender and migration on epidemiology and management

BACKGROUND

The epidemiology and management of diseases can be influenced by social demographic factors. Gender and migration are among these factors.

METHODS

We aimed at reviewing the impacts of gender and migration on rheumatic heart disease (RHD) epidemiology and management by a nonsystematic literature review of published studies on RHD worldwide. Our PubMed search terms included RHD pathophysiology, diagnosis, complications, management or prevention, combined with words 'rheumatic mitral stenosis (MS)', 'outcomes after percutaneous balloon mitral valvuloplasty (PBMV)', 'gender or sex difference' and 'migration'. The reporting of this study conforms to SANRA (the Scale for Assessment of Narrative Review Articles) guidelines.

RESULTS

We retrieved eight studies about the impact of sex on outcomes after PBMV. All of these studies showed a female predominance for RHD. Two studies showed that there is no impact, three studies showed female sex as a predictor of poor outcomes, and the other three showed male sex a predictor of poor outcomes. Although RHD is reported to be eradicated in the developed countries, 2.1% of refugees recently screened for RHD in Italy were found to have subclinical RHD. This prevalence is similar to those found in India (2.0%), Cambodia (2.2%) and Mozambique (3%).

CONCLUSIONS

There are contradicting results for outcomes after PBMV between males and females. It is not clear whether sex difference plays a role in pathophysiology, diagnosis, management and prognosis of MS. Migration has impacts on epidemiology and management of RHD. Further studies are required in these two fields to explore their relationship to RHD.

Poor outcome following percutaneous balloon mitral valvotomy in patients with atrial fibrillation

Introduction: Atrial fibrillation (AF) is the most common arrhythmia in patients with mitral stenosis (MS) and it may increase complications and decreases success rates of percutaneous balloon mitral valvotomy (PBMV). This study aimed to investigate the short and long term results of PBMV in patients with AF compared to sinus rhythm (SR).

Methods: In this cross sectional study, 1000 patients with MS who had undergone PBMV between 1999 and 2013 were enrolled including 585 and 415 patients with AF and SR respectively. Patients were followed for a mean of 7.27 ± 3.16 years. Clinical, echocardiographic and hemodynamic data were collected. Procedure success, in-hospital and long-term outcome were evaluated.

Results: Patients with AF were older and had greater symptoms, mitral regurgitation, mitral echocardiographic score, and mitral pressure gradient before PBMV. PBMV success rate were significantly lower in AF group (P < 0.001). In-hospital complications, including severe mitral regurgitation, emergency mitral valve surgery, peripheral embolism and long-term complications, including mortality, re-valvotomy, mitral replacement surgery and peripheral embolism/stroke were significantly higher in patients with AF.

Conclusion: AF leads to worse in-hospital and long-term outcome and lower PBMV success rate. Repeated assessment and early decision to PBMV in patients with MS to reduce AF and AF related complication seems necessary.

Update on percutaneous mitral commissurotomy

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.

Electrocardiographic P-wave Indices as a Useful Tool to Predict Successful Percutaneous Balloon Mitral Valvotomy in Patients with Mitral Stenosis

Introduction : Patients with hemodynamically significant mitral stenosis (MS) have prolonged P-wave duration and increased P-wave dispersion (PWD) that decrease after successful percutaneous balloon mitral valvotomy (PBMV). The purpose of this study was to investigate if the changes in these indices may predict a successful procedure. Methods : Fifty two patients with MS in sinus rhythm underwent PBMV (90.4% female; mean age 38±10 years). Mitral valve area (MVA), valve score, mean diastolic mitral gradient (mMVG), mitral regurgitation severity, and systolic pulmonary artery pressure (sPAP) were evaluated by echocardiography before PBMV and repeated after one month. P-wave duration (Pmax /Pmin) and PWD were measured before and immediately after PBMV, at discharge, and at the end of the first month after discharge. Results : Among all procedures, 38 (73.1%) were defined as successful. Mean age, valve score, mMVG, and MVA before PBMV were similar for both groups. MVA was significantly greater in the successful PBMV group (1.65±0.27 vs. 1.41±0.22; P= 0.003). sPAP was reduced after PBMV in all patients and there were no significant differences in the mean sPAP before and after PBMV in both successful and unsuccessful groups. Pmax and PWD were significantly decreased immediately after the procedure (P= 0.035), the next day (P= 0.005) and at one month (P= 0.002) only in patients with successful PBMV. Pmin did not change significantly in either group. Conclusion : Only is successful PBMV associated with a decrease in Pmax and PWD. These simple electrocardiographic indices may predict the success of the procedure immediately after PBMV.

Mitral regurgitation after percutaneous balloon mitral valvotomy in patients with rheumatic mitral stenosis: a single-center study

BACKGROUND

Percutaneous balloon mitral valvotomy (BMV) is the gold standard treatment for rheumatic mitral stenosis (MS) in that it causes significant changes in mitral valve area (MVA) and improves leaflet mobility. Development of or increase in mitral regurgitation (MR) is common after BMV. This study evaluated MR severity and its changes after BMV in Iranian patients.

METHODS

We prospectively evaluated consecutive patients with severe rheumatic MS undergoing BMV using the Inoue balloon technique between February 2010 and January 2013 in Madani Heart Center, Tabriz, Iran. New York Heart Association (NYHA) functional class and echocardiographic and catheterization data, including MVA, mitral valve mean and peak gradient (MVPG and MVMG), left atrial (LA) pressure, pulmonary artery systolic pressure (PAPs), and MR severity before and after BMV, were evaluated.

RESULTS

Totally, 105 patients (80% female) at a mean age of 45.81 ± 13.37 years were enrolled. NYHA class was significantly improved after BMV: 55.2% of the patients were in NYHA functional class III before BMV compared to 36.2% after the procedure (p value < 0.001). MVA significantly increased (mean area = 0.64 ± 0.29 cm(2) before BMV vs. 1.90 ± 0.22 cm(2) after BMV; p value < 0.001) and PAPs, LA pressure, MVPG, and MVMG significantly decreased. MR severity did not change in 82 (78.1%) patients, but it increased in 18 (17.1%) and decreased in 5 (4.8%) patients. Patients with increased MR had a significantly higher calcification score (2.03 ± 0.53 vs.1.50 ± 0.51; p value < 0.001) and lower MVA before BMV (0.81 ± 0.23 vs.0.94 ± 0.18; p value = 0.010). There were no major complications.

CONCLUSION

In our study, BMV had excellent immediate hemodynamic and clinical results inasmuch as MR severity increased only in some patients and, interestingly, decreased in a few. Our results, underscore BMV efficacy in severe MS. The echocardiographic calcification score was useful for identifying patients likely to have MR development or MR increase after BMV.

[Immediate results of repeat percutaneous mitral valvuloplasty]

Percutaneous mitral valvuloplasty (PMV) has emerged as the procedure of choice in treatment of mitral stenosis and has proved effectiveness in cases of mitral restenosis after surgical commissurotomy. However, this technique is costly, is not devoid of complication and success is not guaranteed. Indications of an attempted redo percutaneous mitral valvuloplasty (redo-PMV) are not well established. Hence the idea to study the immediate results of (re-PMV).

PURPOSE OF WORK

The purpose of this study is to evaluate the immediate results of the re-PMV in patients with mitral restenosis and analyze the different clinical and laboratory findings to determine predictors of success of re-PMV to better selection of candidates for a new attempt PMV.

METHODS

Retrospective study from a series of 40 procedures of re-PMV with the Inoue balloon succeeding a successful initial procedure, collected in the cardiology department of Habib Thameur hospital of Tunis between 1996 and 2011, in which we identified the data of clinical and paraclinical examinations.

RESULTS

The mean age of patients was 43 ± 11 years [23; 63]. Of the population, 87.5% were female (five men and 35 women). The average time between the two procedures was 8 ± 4 years [1; 15]. The immediate procedural success defined by a mitral valve area greater or equal to 1.5 cm(2) and a grade less than or equal to 2 mitral regurgitation was obtained in 31 patients (77.5%). A severe mitral regurgitation (MR) was observed in three patients (7.5%). A cerebrovascular stroke occurred in one patient (2.5%). No death or cardiac tamponade were noted. Class III or IV of NYHA, a pre-procedural MR, pulmonary hypertension and an overall score of Padial greater than 10 were retained as predictors of failure. More the overall score of Wilkins is high (>8), more it is predictive of failure. The two components of the Wilkins score: valvular mobility and subvalvular apparatus (SVA) and the parameter of the redesign of the SVA score of Padial considered separately are also predictive of failure. Only a left atrial area less than or equal to 25 cm(2) was linked to high risk of severe MR.

CONCLUSION

Redo percutaneous mitral valvuloplasty is a therapeutic alternative to surgery that is effective and promising interesting immediate results. Analysis of clinical and mainly echographic parameters is useful for predicting the success of the gesture, which will allow a better selection of candidates for re-PMV.