Percutaneous mitral valvotomy with the Inoue balloon catheter in children and adults: immediate results and early follow-up

Balloon Mitral Valvotomy With the Accura Double-Lumen Balloon Catheter: Immediate and One-Year Clinical Outcomes

Objective

Despite the decline in the incidence of rheumatic heart disease in developed countries, the disease still remains endemic among individuals of low socioeconomic status. The aim of the study is to assess immediate and one-year outcomes of balloon mitral valvotomy using the double-lumen Accura balloon (Vascular Innovations Co., Nonthaburi, Thailand) in patients with mitral valve stenosis.

Methods

This was a single-centre, observational, investigator-initiated retrospective study. All consecutive patients undergoing balloon mitral valvotomy with the Accura balloon between January 2015 and June 2020 were included. The primary endpoint was procedural success defined as an increase in mitral valve area (MVA) ≥50% from basal valve area or final valve area of ≥1.5 cm², in the absence of mitral regurgitation grade >2. Clinical, echocardiographic, and haemodynamic parameters were assessed at the one-year follow-up.

Results

A total of 62 patients underwent balloon mitral valvotomy. The mean age was 34.9 ± 8.0 years, and 54 (87.1%) patients were female. Mean Wilkins' echo score was 7.5 ± 0.5. Procedural success was achieved in 59 (96.7%) patients. Mean MVA increased from 0.75 ± 0.14 cm² to 1.64 ± 0.21 cm², and mean mitral valve gradient decreased from 24.9 ± 5.5 mmHg to 7.30 ± 1.40 mmHg. Atrial fibrillation, mitral valve replacement, and moderate to severe mitral regurgitation occurred in 36 (59.0%), two (3.3%), and two (3.3%) patients, respectively. No death, cerebrovascular accidents, restenosis, or redo procedures occurred.

Conclusion

Balloon mitral valvotomy using the double-lumen Accura balloon is safe in patients with mitral valve stenosis.

Very Long Term Follow-Up After Percutaneous Balloon Mitral Valvuloplasty

OBJECTIVES

The aim of this study was to assess very long term outcomes after successful percutaneous balloon mitral valvuloplasty (PBMV).

BACKGROUND

PBMV remains the preferred treatment for patients with severe symptomatic rheumatic mitral stenosis and suitable anatomy.

METHODS

All consecutive patients who underwent successful PBMV between 1987 and 2010 were included. The primary endpoint was the composite of all-cause mortality, need for mitral surgery, or repeat PBMV up to 23 years.

RESULTS

Among all 1,582 consecutive patients undergoing PBMV, acute success was achieved in 90.9% (n = 1,438). Independent predictors of acute success included left atrial size (odds ratio: 0.96; 95% confidence interval [CI]: 0.93 to 0.99; p = 0.045), Wilkins score ≤8 (odds ratio: 1.66; 95% CI: 0.48 to 0.93; p = 0.02) and age (odds ratio: 0.97; 95% CI: 0.96 to 0.99; p = 0.006). Very long term follow-up (median 8.3 years, mean 15.6 years) was obtained in 79.1% of successful cases. The incidence of the primary endpoint was 19.1% (95% CI: 17.0% to 21.1%). The rates of overall mortality, need for mitral valve surgery, or repeat PBMV were 0.6% (95% CI: 0.3% to 1.2%), 8.3% (95% CI: 7.0% to 9.9%), and 10.0% (95% CI: 8.5% to 11.7%), respectively. On multivariate analysis, New York Heart Association functional class III or IV (hazard ratio: 1.62; 95% CI: 1.26 to 2.09; p < 0.001), higher age (hazard ratio: 0.97; 95% CI: 0.96 to 0.98; p = 0.028), and mitral valve area ≤1.75 cm² after the procedure (hazard ratio: 1.67; 95% CI: 1.28 to 2.11; p = 0.028) were independent predictors of the primary endpoint.

CONCLUSIONS

In very long term follow-up, more than 75% of patients exhibited sustained results. Prediction of late favorable results is multifactorial and strongly determined by age, previous symptoms and post-procedural mitral valve area.

Intermediate outcomes of rheumatic mitral stenosis post-balloon mitral valvotomy

Background

Balloon mitral valvotomy is a standard therapeutic modality for managing rheumatic mitral stenosis. Data on intermediate outcomes of this procedure are limited. Thus we investigated the intermediate outcome after balloon mitral valvotomy performed at a large tertiary center in India.

Methods

Case records and follow-up data of 2330 patients who underwent valvotomy from June 1999 to December 2005 were retrieved from the hospital information system and analyzed.

Results

The median age of the patients was 32 ± 11 years, 1363 were female including 36 who were pregnant, and 379 were in atrial fibrillation. Follow-up ranged from 1 to 14 years (mean 4.5 years, median 4.0 years). The procedural success rate was 93%. Atrial fibrillation, higher functional class, and worse valve morphology were independent predictors of a poor procedural outcome. Patients with sinus rhythm had better event-free survival (10.43 years, 95% confidence interval: 10.1–10.7) compared to those with atrial fibrillation (8.17 years, 95% confidence interval: 7.5–8.8). Patients who achieved a valve area >1.75 cm2 had a better event-free survival (11.7 years, 95% confidence interval: 11.4–12.0) than those with a valve area of 1.5–1.74 cm2 (9.3 years, 95% confidence interval: 9.0–9.7). On multivariate analysis, higher functional class, worse valve morphology, and new significant mitral regurgitation were predictors of a poor outcome. Achieved mitral valve area >1.75 cm2 was an independent predictor of a good outcome.

Conclusion

Patients with sinus rhythm, less gross valve deformity, and a post-balloon mitral valvotomy area >1.75 cm2 had better intermediate outcomes.

Long-Term Results up to 19 Years of Mitral Balloon Valvuloplasty

Clinical and echocardiographic data of 547 consecutive patients (mean age, 31.5 years) undergoing mitral balloon valvuloplasty with follow-up of 1.5–19 years, were analyzed. Immediately after valvuloplasty, mitral valve area increased significantly from 0.92 ± 0.17 to 1.95 ± 0.29 cm2. Restenosis occurred in 169 (31%) patients; it was less common (20%) in those with a mitral echocardiographic score ≤8. Actuarial freedom from restenosis at 10, 15, and 19 years was 78% ± 2%, 52% ± 3%, and 26 ± 4%, respectively, and significantly higher in patients with echocardiographic scores ≤8: 88% ± 2%, 67% ± 4%, and 40% ± 6%, respectively. Event-free survival at 10, 15, and 19 years was 88% ± 2%, 60% ± 4%, and 28% ± 7%, respectively, and significantly higher in patients with echocardiographic scores ≤8: 92% ± 1%, 70% ± 4%, and 42% ± 7%, respectively. Multivariate analysis identified echocardiographic score ≤8 and post-procedure valve area ≤1.8 as predictors of restenosis, and echocardiographic score > 8 and preexisting atrial fibrillation as predictors of combined events. Valvuloplasty provides excellent results in selected patients with mitral stenosis. The long-term outcome can be predicted from the baseline characteristics of the mitral valve.

The impact of mitral valve morphology on the long-term outcome of mitral balloon valvuloplasty

BACKGROUND

The effect of mitral valve morphology (MVM) on the long-term results of mitral balloon valvuloplasty (MBV) is not well established. The aim of the study was to evaluate the impact of MVM on long-term outcome of MBV.

METHODS

Five hundred and eighteen consecutive patients (mean age, 31+/-11 years) who underwent successful MBV were followed up for 0.5-16.5 (mean, 6+/-4.5) years. Patients were divided into two groups according to their mitral echo score (MES) before MBV: group A (n=340; MES<or=8) and group B (n=178; MES>8).

RESULTS

We report the immediate and long-term clinical and echocardiographic results of the above-mentioned 518 consecutive patients. The mitral valve area was significantly larger in group A than in group B, both immediately after MBV (2.0+/-0.3 vs. 1.82+/-0.3 cm2, respectively; P<0.0001) and also at the last follow-up (1.8+/-0.33 vs. 1.5+/-0.33 cm2, respectively; P<0.0001). Restenosis occurred in 38/340 (11%) in group A vs. 73/178 (41%) in group B (P<0.0001). Actuarial freedom from restenosis at 5, 10, 15 years were 92+/-2%, 85+/-3%, 65+/-6% for group A vs. 72+/-4%, 44+/-5%, 9+/-6% for group B (P<0.001). Event-free survival rates at 5, 10, 15 years for group A were 93+/-1%, 88+/-2%, 66+/-6% vs. 82+/-3%, 59+/-6%, 8+/-7% for group B (P<0.0001). Stepwise Cox multivariate regression analysis identified MES, preprocedure functional class, and postprocedure mitral valve area<or=1.8 cm2, as predictors of restenosis (P<0.0001, P=0.014, P=0.0015, respectively); MES and age as predictors of event-free survival (P<0.0001, P<0.0001, respectively).

CONCLUSION

MBV has excellent long-term results in patients with favorable MVM. Favourable MVM is a strong predictor of good long-term outcome.

Long-Term Results (Up to 16.5 Years) of Mitral Balloon Valvuloplasty in a Series of 518 Patients and Predictors of Long-Term Outcome

OBJECTIVES

To assess the long-term results (up to 16.5 years) of mitral balloon valvuloplasty (MBV) and to identify predictors of restenosis and event-free survival.

METHODS AND RESULTS

We report the immediate and long-term clinical and echocardiographic results in 518 patients, mean age 31 +/- 11 years, who underwent successful MBV for severe mitral stenosis (MS) and were followed up for 0.5-16.5 (mean 6 +/- 4.5) years. After MBV, mitral valve area (MVA) increased from 0.84 +/- 0.2 to 1.83 +/- 0.53 cm(2) (P < 0.0001) as measured by catheter and from 0.92 +/- 0.17 to 1.96 +/- 0.29 cm(2) (P < 0.0001) as measured by two-dimensional echo. Restenosis occurred in 111 patients (21%) and it was less frequent in patients with low echo score (11%). Actuarial freedom from restenosis at 5, 10, 15 years was 85 +/- 1%, 70 +/- 3%, and 44 +/- 5%, respectively, and was significantly higher in patients with low echo score. Event-free survival (death, redo MBV, mitral valve replacement, New York Heart Association [NYHA] functional class III or IV) at 5, 10, 15 years was 89 +/- 1%, 79 +/- 2%, 43 +/- 9%, respectively, and was significantly higher for patients with low echo score. Cox regression analysis identified mitral echocardiographic score (MES) > 8 (P < 0.0001), postprocedure mitral valve area (MVA) (P = 0.0015), and preprocedure functional class (P = 0.014) as predictors of restenosis and MES (P < 0.0001) and age (P < 0.0001) and postprocedure MVA (P = 0.015) as predictors of event-free survival.

CONCLUSIONS

MBV provides excellent long-term results for selected patients with MS. The long-term outcome after this procedure can be predicted from baseline clinical and echocardiographic characteristics.

Favorable effect of balloon mitral valvuloplasty on the incidence of atrial fibrillation in patients with severe mitral stenosis

BACKGROUND

The long-term effect of balloon mitral valvuloplasty (BMV) on the incidence of atrial fibrillation (AF) in patients with severe mitral stenosis (MS) remains undetermined.

AIMS

To assess the effect of successful BMV on the incidence of chronic AF in patients with severe MS, compare the results with historical controls, and identify factors associated with AF in such patients.

METHODS

Retrospective analysis of 382 consecutive patients with severe MS and in sinus rhythm (SR) who underwent successful BMV (post procedure mitral valve area (MVA) > or =1.5 cm(2), mitral regurgitation (MR) < or =2/4) at our hospital and followed-up for 1-15.6 (mean 5.6 +/- 3.9) years with clinical and echocardiographic examination.

RESULTS

Thirty-four (8.9%) patients developed AF at follow-up (group A) and 348 patients (group B) remained in SR. At baseline, and in comparison with group B, patients who developed AF (group A) were older, had higher mitral echo score but equal MVA and left atrial (LA) size. The postprocedure MVA was smaller in group A (1.7 +/- 0.3 cm(2)) than in group B (2.0 +/- 0.2 cm(2;) P = 0.002). At follow-up, and in comparison to group B, group A had smaller MVA (1.5 +/- 0.4 cm(2) vs 1.8 +/- 0.4 cm(2) P <0.0001), larger LA dimension (49.4 +/- 6.5 vs 42 +/- 6.5 mm; P <0.0001) and higher restenosis rate (35% vs 14%; P = 0.001). Multivariate logistic regression analysis identified age at follow-up (P < 0.0001), LA size at follow-up (P = 0.004), and MVA at follow-up (P = 0.006) as predictors of AF.

CONCLUSIONS

This study demonstrated favorable effect of BMV on the incidence of AF (8.9%) in patients with severe MS in comparison with reported series (29%) of patients with severe MS with similar baseline characteristics who were not submitted to any intervention. The predictors of AF were age, larger LA, and smaller MVA, at follow-up.

Immediate and long-term results of mitral balloon valvotomy for restenosis following previous surgical or balloon mitral commissurotomy

This study compared immediate with long-term results of mitral balloon valvotomy (MBV) in patients who underwent MBV as an initial procedure versus those who underwent repeat MBV. Fifty-six patients who were a mean age of 28 +/- 8.8 years (group A) and had mitral restenosis after surgical or balloon commissurotomy underwent MBV and were compared with 524 patients who were a mean age of 31 +/- 11 years (group B) and underwent MBV as an initial procedure. Prospective data obtained included demographic, hemodynamic, echocardiographic, and clinical follow-up for 0.5 to 15 years after MBV. No deaths or technical failure were encountered after MBV. Mitral regurgitation >2/4 occurred in 1 patient (2%) in group A and in 9 patients (2%) in group B (p = 0.24). Fifty-two of 56 patients (93%) in group A had good immediate results (mitral valve area >or=1.5 cm(2), mitral regurgitation <2/4), as did 504 of 524 patients (96%) in group B (p = 0.4). Actuarial values for freedom from restenosis at 10 years were 58 +/- 7% for group A versus 69 +/- 3% for group B (p = 0.18). Ten-year event-free survival rate was 54 +/- 7% for group A versus 80 +/- 3% for group B (p <0.005). The predictors of event-free survival were age (p = 0.003), echocardiographic score (p <0.0001), and baseline atrial fibrillation (p = 0.01). In conclusion, MBV is safe and provides good immediate results in patients who have restenosis. Long-term results are inferior compared with de novo mitral stenosis but is still satisfactory. More than 50% of patients remained improved at 10 years, thus enabling the operation or reoperation to be deferred.

Long-term clinical and echocardiographic results after successful mitral balloon valvotomy and predictors of long-term outcome

AIMS

To assess the long-term outcome of mitral balloon valvotomy (MBV) and identify predictors of restenosis- and event-free survival.

METHODS AND RESULTS

We report the immediate and long-term clinical and echocardiographic results in 493 patients, mean age 31+/-11, who underwent successful MBV and were followed-up for 0.5-15 years (median 5+/-3) with clinical and echocardiographic examination. After MBV, mitral valve area increased from 0.84+/-0.2 to 1.83+/-0.53 cm(2) (P<0.0001) as measured by catheter and from 0.92+/-0.17 to 1.96+/-0.29 cm(2) as measured by two-dimensional echo. Restenosis occurred in 86/493 (17.4%) patients and it was less frequent in patients with low echo score. Actuarial freedom from restenosis at 5, 7, 10, and 13 years were 89+/-1, 81+/-2, 68+/-3, and 51+/-6%, respectively, and was significantly higher in patients with low echo score. Event-free survival (death, redo MBV, mitral valve replacement, New York Heart Association functional Class III or IV) at 5, 7, 10, and 13 years were 92+/-1, 87+/-2, 80+/-3, and 74+/-3%, respectively, and was significantly higher for patients with low echo score. Cox regression analysis identified mitral echocardiographic score (MES) >8 as predictors of restenosis (P=0.0004) and MES and age as predictors of event-free survival (P=0.0003 and 0.004, respectively).

CONCLUSION

MBV has excellent long-term results for selected patients with mitral stenosis. The long-term outcome after this procedure can be predicted from baseline clinical and valvular characteristics.

Immediate and long-term results of percutaneous mitral balloon valvotomy in asymptomatic or minimally symptomatic patients with severe mitral stenosis

The purpose of this study was to evaluate the safety and value of percutaneous mitral balloon valvotomy (PMBV) in asymptomatic or minimally symptomatic patients with severe mitral stenosis (MS). There are very limited data supporting the concept of PMBV in asymptomatic or minimally symptomatic patients with severe MS. We analyzed the results of 539 consecutive patients with severe MS who underwent PMBV at our hospital. Patients were divided according to their symptoms at the time of PMBV into group A (55 patients), who had few or no symptom (NYHA class 1 or 2), and group B (484 patients), who had severe symptom (NYHA class 3 or 4). Patients had clinical and echocardiographic follow-up for 0.5-15 years. There was no significant difference in baseline characteristics between the two groups. The immediate mitral valve area (MVA) was equal in both groups. The follow-up MVA was larger in group A (1.9 +/- 0.38 vs. 1.7 +/- 0.4 cm(2); P = 0.002), and restenosis occurred in 11% in group A vs. 23% in group B (P = 0.023). Actuarial freedoms from restenosis at 5, 10, and 13 years were significantly higher for group A than for group B (97% +/- 2%, 77% +/- 9%, 77% +/- 9% vs. 85% +/- 1%, 62% +/- 3%, 39% +/- 5%; P = 0.0018). Atrial fibrillation at follow-up was encountered in 11% in group A vs. 20% in group B (P = 0.042). There was a significant reduction of the left atrial size in both groups. Event-free survivals at 5, 10, and 13 years were higher for group A than for group B (97% +/- 2%, 80% +/- 9%, 80% +/- 9% vs. 86% +/- 1%, 65% +/- 3%, 42% +/- 3%; P = 0.0018). This study demonstrated excellent immediate results of PMBV in asymptomatic or minimally symptomatic patients with severe MS and long-term results are better compared to the reported natural history of such patients. We recommend mitral balloon valvotomy (MBV) for patients with severe MS with few or no symptoms, provided the valve morphology is suitable for MBV.

Regression of significant tricuspid regurgitation after mitral balloon valvotomy for severe mitral stenosis

BACKGROUND

Significant tricuspid regurgitation (TR) is occasionally associated with severe mitral stenosis and has an adverse impact on morbidity and mortality in patients undergoing mitral valve surgery. However, the effect of successful mitral balloon valvotomy (MBV) on significant TR is not fully elucidated. The aim of this study was to investigate TR after MBV in patients with severe mitral stenosis.

METHODS

We analyzed the data of 53 patients with significant TR (grade > or =2, on a 1 to 3 scale) from the mitral balloon valvotomy database at our hospital. Patients were evaluated by Doppler echocardiography before valvotomy and at follow-up 1 to 13 years after MBV. Patients were divided into group A (27 patients), in whom TR regressed by > or =1 scale, and group B (26 patients), in whom TR did not regress.

RESULTS

The Doppler-determined pulmonary artery systolic pressure was initially higher and decreased at follow-up more in group A (from 70.7 +/- 23.8 to 36.5 +/- 8.3 mm Hg; P < .0001) than in group B (from 48.7 +/- 17.8 to 41.6 +/- 13.1 mm Hg; P = NS). Compared with patients in group B, patients in group A were younger (25 +/-10 vs 35 +/- 11 years; P < .005), had higher prevalence of functional TR (85% vs 8%; P < .0001), and had lower incidence of atrial fibrillation (7% vs 38%; P < .005). Significant decrease in right ventricular end-diastolic dimension after MBV was noted in group A but not in group B. The mitral valve area at late follow-up was larger in group A than in group B (1.8 +/- 0.3 vs 1.6 +/- 0.3 cm2; P < .05).

CONCLUSIONS

Regression of significant TR after successful MBV in patients with severe mitral stenosis was observed in patients who had severe pulmonary hypertension. This improvement in TR occurred even in the presence of organic tricuspid valve disease.

Immediate and long-term effect of mitral balloon valvotomy on left ventricular volume and systolic function in severe mitral stenosis

To determine the immediate and long-term effect of mitral balloon valvotomy (MBV) on left ventricular (LV) volume and function, we studied 17 patients (mean age 27 +/- 9 years) with severe mitral stenosis undergoing MBV by cardiac catheterization and angiography before and immediately after MBV and at mean 12 months later. At baseline, LV end-diastolic volume index (EDVI) was reduced. Ten patients had EDVI < or = 55 ml/m2, and four patients (23.5%) had LV ejection fraction < 50%. EDVI increased from 60 +/- 17 ml/m2 to 66 +/- 17 ml/m2 (p < 0.05) immediately after MBV and increased further to 72 +/- 16 ml/m2 (p < 0.05) later. Stroke volume index increased from 34 +/- 10 ml/m2 to 41 +/- 12 ml/m2 (p < 0.05) immediately after MBV and increased further to 50 +/- 11 ml/m2 (p < 0.001) later. LV end diastolic pressure increased from 12 +/- 5 mm HG to 16 +/- 4 mm HG (p < 0.05) immediately after MBV and fell to 13 +/- Hg at follow-up. LV ejection fraction increased from 57 +/- 7% to 62 +/- 6% (p < 0.05) immediately after MBV and 71 +/- 8% later (p < 0.001). Mean systolic ejection rate increased from 82 +/- 35 ml/sec to 101 +/- 48 ml/sec (p < 0.05) immediately after and 165 +/- 81 ml/sec later (p < 0.05). Systemic vascular resistance fell from 1887 +/- 525 dyne/sec/cm-5 to 1280 +/- 231 dyne/sec/cm-5 (p < 0.001) at follow-up. We conclude that the LV end-diastolic volume and systolic function are reduced in patients with mitral stenosis, and the LV end-diastolic volume is increased immediately after MBV and continues to increase at follow-up 12 months later; the LV ejection performance improves after successful MBV because of an increase in end-diastolic LV volume (preload) and reduction of SVR.

Advantage of Inoue balloon catheter in mitral balloon valvotomy: experience with 220 consecutive patients

Percutaneous mitral balloon valvotomy (PMV) using the Inoue balloon catheter was attempted in 220 consecutive patients with severe symptomatic mitral stenosis. Their age range was 10-63 mean 30 +/- 10 years; 161 patients were females and 59 were males; 29 patients were in atrial fibrillation. Eleven patients were pregnant; 14 patients underwent previous surgical commissurotomy. The procedure was technically successfully performed in 215 (97.7%) patients. The mean fluoroscopy time was 15.5 +/- 6.4 min and mean procedure time was 109 +/- 79 min. Optimal results (group I) was achieved in 207 patients who have mitral score of 7 +/- 1. PMV resulted in decrease in left atrial pressure from 23 +/- 5 to 14 +/- 4 mm Hg (P < 0.001), the mean mitral valve gradient (MVG) decreased from 15 +/- 4 to 6 +/- 3 mm Hg (P < 0.001). The mitral valve area (MVA) by catheter increased from 0.7 +/- 0.2 to 1.7 +/- 0.5 cm2 (P < 0.001) and MVA as determined by echocardiography (2DE) increased from 0.8 +/- 0.1 to 1.9 +/- 0.3 cm2 (P < 0.001). The results were suboptimal in eight patients who have a mitral score of 10 +/- 1 (group II) MVA by catheter increased from 0.7 +/- 0.2 to 1 +/- 0.1 cm2 and Doppler MVA increased from 0.8 +/- 0.1 to 1.3 +/- 0.1 cm2. There were no deaths or thromboembolism. Two patients developed cardiac tamponade; mild mitral regurgitation (MR) developed in 24 patients (11%) and increased by one grade in another 22 patients (10%). Severe MR was encountered in three patients (1.4%). A small ASD (QP/QS < or = 1.3) was detected by oximetry in 5% of patients and by color-flow mapping in 26% of patients. One hundred fifty-eight patients from group I were followed up, for a mean of 32 +/- 12 months; MVA remained at 1.7 +/- 0.4 cm2. Seven patients developed mitral restenosis in group I, and 5 out of 8 patients developed restenosis in group II. We conclude that the hemodynamic results are good and comparable with those reported with double balloon technique. However, the Inoue balloon has several advantages over the double balloon technique: (1) low incidence of mitral regurgitation and ASDs; (2) shorter procedure and fluoroscopy time; and (3) low complication rates and the valve anatomy affects the immediate and late outcome of mitral balloon valvotomy.

Pitfalls and tips in inoue balloon mitral commissurotomy

Balloon mitral commissurotomy is a safe and effective alternative therapeutic modality in selected patients with significant rheumatic mitral stenosis. Since its introduction in 1984, Inoue balloon mitral commissurotomy has gained wider acceptance over other balloon valvuloplasty techniques because it is technically less demanding and associated with fewer complications. Nevertheless, certain pitfalls which may make the procedure more difficult or create complications are sometimes encountered. In this article, we offer tips to facilitate a safe and expeditious execution of Inoue balloon mitral commissurotomy based on our experience with over 1,000 procedures.

Immediate and long-term effect of mitral balloon valvotomy on severe pulmonary hypertension in patients with mitral stenosis

The pulmonary vascular hemodynamics were studied in 21 patients with severe mitral stenosis and severe pulmonary hypertension. Hemodynamic data were obtained before and immediately after mitral balloon valvotomy (MBV) and at follow-up 7 to 14 months (mean 12 months) later by repeat catheterization. The mean pulmonary capillary wedge pressure (PCW) decreased from 27 +/- 5 to 15 +/- 4 mm Hg (p < 0.001). The mean mitral valve gradient (MVG) decreased from 18 +/- 4 to 6 +/- 2 mm Hg (p < 0.001). Mitral valve area (MVA) increased from 0.6 +/- 0.1 to 1.5 +/- 0.3 cm2 (p < 0.02). Cardiac index increased from 2.2 +/- 0.3 to 2.6 to 0.5 L/min/m2 (p < 0.02). The pulmonary artery systolic pressure decreased from 65 +/- 13 to 50 +/- 13 mm Hg (p < 0.001), and no significant change was seen in pulmonary vascular resistance (PVR) immediately after MBV from 461 +/- 149 to 401 +/- 227 dynes/sec/cm(-5) (p = 0.02). At follow-up the MVA increased from 1.5 +/- 0.3 to 1.7 +/- 0.3 cm2 (p < 0.02). Cardiac index increased further to 3 +/- 0.4 L/min/m2 (p < 0.02). MVG and PCW pressure remained the same. The pulmonary artery systolic pressure decreased further to 38 +/- 9 mm Hg (p < 0.02). PVR decreased significantly to 212 +/- 99 dynes/sec/cm(-5) (p < 0.02). We concluded that the pulmonary artery pressure decreased without normalizing immediately after MBV and normalized in patients with optimal results from mitral balloon valvotomy 7 to 14 months later. Insignificant change in PVR was seen immediately after MBV and markedly decreased or normalized at late follow-up in patients with optimal result from MBV.

Controversies in balloon mitral valvuloplasty: the when (timing for intervention), what (choice of valve), and how (selection of technique)

Despite the established role of percutaneous balloon mitral valvuloplasty (BMV) in the treatment of mitral stenosis, major controversial issues in the realm of BMV persist. With increased operator experience, BMV has now been extended to include various controversial scenarios, such as mild mitral stenosis, adverse valve morphologies, and high-risk patients with concomitant anatomic distortions which are technically demanding. In skilled hands, however, BMV has yielded a favorable outcome in these settings. Furthermore, the debate on whether the Inoue or the double-balloon approach is superior continues. Studies to date have shown equal efficacy of the two BMV methods in terms of valve enlargement although the Inoue approach is clearly simpler to execute and may potentially be associated with a lower risk of creating severe mitral regurgitation. Last, because of the lack of consensus on optimal balloon sizing for BMV, perhaps the best method to adopt at this stage is one that is simple and safe to apply across a broad spectrum of valve anatomy.

A simple balloon-sizing method in Inoue-balloon percutaneous transvenous mitral commissurotomy

This study was carried out to examine whether the previously determined balloon sizing method based on patient height was valid for percutaneous transvenous mitral commissurotomy using the current second-generation Inoue balloon catheter. The study consisted of 70 patients with pliable noncalcified mitral valves (group 1) and 85 patients with calcified mitral valves and/or severe subvalvular lesions (group 2). The mitral valve area was increased more in group 1 than in group 2 (1.0 +/- 0.3 to 1.9 +/- 0.5 cm2 versus 1.0 +/- 0.3 to 1.6 +/- 0.5 cm2, P = 0.002). Using the stepwise dilatation technique, none of the group 1 patients developed severe mitral regurgitation. Severe mitral regurgitation occurred in 4 patients (4.7%) in group 2. In conclusion, a simple balloon sizing method based on body height for selection of an appropriate-sized balloon catheter, as well as an initial inflated balloon diameter for the stepwise dilatation technique is useful for optimal acute outcomes in mitral commissurotomy.

Mitral balloon valvotomy in children with Inoue balloon technique: immediate and intermediate-term result

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

Urgent/emergent percutaneous transvenous mitral commissurotomy

Urgent/emergent percutaneous transvenous mitral commissurotomy (PTMC) was performed in 10 patients (two men and eight women, aged 21 to 60 yr). All patients had arterial hypoxemia and four required mechanical respirators. PTMC was performed in the semi-recumbent position in four patients. The seven patients with pliable valves (group 1) achieved good hemodynamic and echocardiographic results after PTMC, but one died 2 wk later because of sepsis complicating preexisting pneumonitis. The two pregnant patients uneventfully delivered normal babies at term. There was continued clinical improvement in the six surviving patients at last follow-up at 11 to 39 mon (median 26). Of the three patients with calcified valves and severe subvalvular lesions (group 2), the premoribund patient in whom last-resort PTMC created severe mitral regurgitation died 3 days later of multiple organ failure. The other two patients underwent mitral valve replacement 1-6 days later because of lack of clinical improvement due to creation of severe mitral regurgitation and ineffective mitral valve dilation, respectively. In conclusion, urgent/emergent PTMC is feasible and safe. However, its outcomes are dictated by the status of diseased mitral valve and coexisting illness.

Mitral restenosis and mitral regurgitation 1 year after Inoue mitral balloon valvotomy in a population of patients with pliable mitral valve stenosis

To determine the rate of mitral restenosis and mitral regurgitation increase 1 year after mitral valvotomy using the Inoue balloon catheter, 66 consecutive patients with severe, pliable mitral stenosis had their mitral valve area (MVA) calculated by two-dimensional echocardiography (2DE) and Doppler before, immediately after balloon valvotomy, and at 1-year follow-up. Color Doppler studies were also done to detect small atrial septal defects (ASDs) and mitral regurgitation. The mean age of the patients was 31 +/- 12 years. Three patients were in New York Heart Association (NYHA) class II and 63 patients were in NYHA class III to IV. Sixty-two of the 66 patients had an echo score (Boston) of < or = 8. After Inoue balloon valvotomy (IBV), the MVA (2DE) increased from 0.8 +/- 0.2 to 1.9 +/- 0.3 cm2 (p < 0.001), and the Doppler MVA increased from 0.8 +/- 0.2 to 1.8 +/- 0.3 cm2 (p < 0.001). We detected 4 of 66 cases (6%) with significant residual mitral stenosis (MVA < 1.5 cm2). Mitral regurgitation increased in 14 of 66 patients (21%), but no patient developed severe mitral regurgitation. Fourteen out of 66 patients (20%) had ASDs that were detected on color Doppler. At 1-year follow-up the mean Doppler MVA was maintained at 1.8 +/- 0.4 cm2, with 6 of 66 patients (9%) exhibiting significant mitral valve restenosis. Residual significant mitral stenosis must be differentiated from mitral restenosis.(ABSTRACT TRUNCATED AT 250 WORDS)