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Abdelghani M, Nunes MCP, Anwar AM, Prendergast B. Assessment of suitability for percutaneous mitral commissurotomy: a contemporary review of key anatomical criteria and predictive models. Eur Heart J Cardiovasc Imaging 2024; 25:739-753. [PMID: 38376989 DOI: 10.1093/ehjci/jeae052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 01/31/2024] [Accepted: 02/18/2024] [Indexed: 02/22/2024] Open
Abstract
The immediate result of percutaneous balloon mitral commissurotomy is largely determined by the anatomy of the mitral valve complex. Several scores and models have been developed to assess anatomical suitability for percutaneous balloon mitral commissurotomy. Although none has an optimal predictive power, these models look at the valvular apparatus from different perspectives bearing the potential for a complementary role.
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Affiliation(s)
- Mohammad Abdelghani
- Cardiology Department, Al-Azhar University, Nasr City, 11651 Cairo, Egypt
- Cardiology Unit, Sohar Hospital, Muwelleh Street, 311 Sohar, Oman
- Cardiology Department, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Maria Carmo P Nunes
- Hospital das Clinicas, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Ashraf M Anwar
- Cardiology Department, Al-Azhar University, Nasr City, 11651 Cairo, Egypt
- Department of Cardiology, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Bernard Prendergast
- Department of Cardiology, Guys and St Thomas' NHS Foundation Trust Hospital London, London, UK
- Heart, Vascular & Thoracic Institute, Cleveland Clinic London, London, UK
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Rossignon P, Morra S, de Hemptinne Q, de Cannière D, Unger P. Papillary muscle rupture without severe mitral regurgitation following percutaneous balloon mitral commissurotomy: a case report. Eur Heart J Case Rep 2024; 8:ytae114. [PMID: 38487589 PMCID: PMC10939169 DOI: 10.1093/ehjcr/ytae114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/13/2024] [Accepted: 02/22/2024] [Indexed: 03/17/2024]
Abstract
Background Percutaneous transvenous mitral commissurotomy (PTMC) is the first-line therapy of clinically significant rheumatic mitral stenosis. While the procedure is generally safe, new onset or aggravation of mitral regurgitation (MR) may occur, mainly due to commissural splitting and, less frequently, to leaflet tear and chordal rupture. Papillary muscle rupture (PMR) is exceedingly rare in this setting. Case summary A 74-year-old woman with a history of aortic valve replacement and prior rheumatic mitral commissurotomy presented for worsening exercise intolerance and exertional dyspnoea. Transthoracic echocardiography showed a mean pressure gradient of 10 mmHg and a mitral valve area of 1.0 cm², consistent with clinically significant mitral stenosis. Subsequent PTMC was complicated by anterolateral PMR. However, the resulting MR was unexpectedly only of mild-to-moderate severity. Because of residual mitral stenosis and persisting symptoms, surgical mechanical mitral valve replacement and tricuspid annuloplasty were performed 6 weeks after PTMC. Papillary muscle rupture was confirmed during surgery. Discussion We herein describe the occurrence of PMR induced by PTMC; the resulting MR was unexpectedly of mild-to-moderate severity, as a result of extensive rheumatic lesions limiting valve mobility. This case challenges the dogma according to which PMR invariably leads to severe MR. This might not be necessarily the case when it occurs following PTMC.
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Affiliation(s)
- Pierre Rossignon
- Department of Cardiology, CHU Saint-Pierre, Université Libre de Bruxelles, Rue aux Laines 105, 1000 Brussels, Belgium
| | - Sofia Morra
- Department of Cardiology, CHU Saint-Pierre, Université Libre de Bruxelles, Rue aux Laines 105, 1000 Brussels, Belgium
| | - Quentin de Hemptinne
- Department of Cardiology, CHU Saint-Pierre, Université Libre de Bruxelles, Rue aux Laines 105, 1000 Brussels, Belgium
| | - Didier de Cannière
- Department of Cardiac Surgery, CHU Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Philippe Unger
- Department of Cardiology, CHU Saint-Pierre, Université Libre de Bruxelles, Rue aux Laines 105, 1000 Brussels, Belgium
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Rashid H, Haq ZU, Alam S, Nazir M, Nadir M, Fakhar T, Zaidi SMJ, Mustafa B, Malik J. Procedural complications associated with percutaneous mitral balloon valvotomy: A systematic review. Expert Rev Cardiovasc Ther 2022; 20:929-932. [PMID: 36421070 DOI: 10.1080/14779072.2022.2152328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND As Percutaneous mitral balloon valvotomy (PMBV) remains the keystone in treating mitral stenosis, we conducted this review to elucidate the cumulative frequency and predictors of complications following PMBV and their occurrence in various patient populations. AREAS COVERED We searched digital databases for relevant studies covering complications of PMBV and retrieved articles using the Medical Subject Heading (MeSH) keywords. EXPERT OPINION A total of 37 articles (8 RCTs, 7 nonrandomized clinical trials, 22 observational studies) were selected for qualitative analysis. A total of 11,803 patients undergoing PMBV among 37 studies were included, with a mean success rate of 84.54%. The most common complication was mitral regurgitation (8.2%) followed by an atrial septal defect (2.4%). Other relevant complications like stroke, pericardial tamponade, rupture of mitral leaflets, and conduction abnormalities were present in <1% of the patients.
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Affiliation(s)
- Haroon Rashid
- Department of Critical Care, Wythenshawe Hospital, Manchester, England
| | - Zargham Ul Haq
- Medical Student, Lahore Medical and Dental College, Lahore, Pakistan
| | - Shafiq Alam
- Department of Cardiology, Mardan Medical Complex, Mardan, Pakistan
| | - Maheen Nazir
- Medical Student, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Maha Nadir
- Department of Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, Pakistan
| | - Tehniat Fakhar
- Medical Student, Shifa College of Medicine, Islamabad, Pakistan
| | | | - Bilal Mustafa
- Department of Cardiology, Akbar Niazi Teaching Hospital, Islamabad, Pakistan
| | - Jahanzeb Malik
- Department of Electrophysiology, Armed Forces Institute of Cardiology, Rawalpindi, Pakistan
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Abu Rmilah AA, Tahboub MA, Alkurashi AK, Jaber SA, Yagmour AH, Al-Souri D, Lewis BR, Nkomo VT, Erwin PJ, Reeder GS. Efficacy and safety of percutaneous mitral balloon valvotomy in patients with mitral stenosis: A systematic review and meta-analysis. IJC HEART & VASCULATURE 2021; 33:100765. [PMID: 33889711 PMCID: PMC8050729 DOI: 10.1016/j.ijcha.2021.100765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/11/2021] [Accepted: 03/13/2021] [Indexed: 12/01/2022]
Abstract
Aims Percutaneous mitral balloon valvotomy PMBV is an acceptable alternative to Mitral valve surgery for patients with mitral stenosis. The purpose of this study was to explore the immediate results of PMBV with respect to echocardiographic changes, outcomes, and complications, using a meta-analysis approach. Methods MEDLINE, and EMBASE databases were searched (01/2012 to 10/2018) for original research articles regarding the efficacy and safety of PMBV. Two reviewers independently screened references for inclusion and abstracted data including article details and echocardiographic parameters before and 24–72 h after PMBV, follow-up duration, and acute complications. Disagreements were resolved by third adjudicator. Quality of all included studies was evaluated using the Newcastle-Ottawa Scale NOS. Results 44/990 references met the inclusion criteria representing 6537 patients. Our findings suggest that PMBV leads to a significant increase in MVA (MD = 0.81 cm2; 0.76–0.87, p < 0.00001), LVEDP (MD = 1.89 mmHg; 0.52–3.26, p = 0.007), LVEDV EDV (MD = 5.81 ml; 2.65–8.97, p = 0.0003) and decrease in MPG (MD = −7.96 mmHg; −8.73 to −7.20, p < 0.00001), LAP (MD = −10.09 mmHg; −11.06 to −9.12, p < 0.00001), and SPAP (MD = −15.55 mmHg; −17.92 to −13.18, p < 0.00001). On short term basis, the pooled overall incidence estimates of repeat PMBV, mitral valve surgery, post-PMBV severe MR, and post-PMBV stroke, and systemic thromboembolism were 0.5%, 2%, 1.4%, 0.4%, and 0.7%% respectively. On long term basis, the pooled overall incidence estimates of repeat PMBV, mitral valve surgery, post-PMBV severe MR, and post-PMBV stroke, systemic thromboembolism were 5%, 11.5%, 5.5%, 2.7%, and 1.7% respectively Conclusion PMBV represents a successful approach for patients with mitral stenosis as evidenced by improvement in echocardiographic parameters and low rate of complications.
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Key Words
- AF, Atrial fibrillation
- AHA/ACC, American Heart Association (AHA) and American College of Cardiology (ACC)
- Echocardiography
- LAD, Left atrial diameter
- LAP, Left atrial pressure
- LV EDP, Left ventricle end-diastolic pressure
- LV EDV, Left ventricle end-diastolic volume
- LV ESP, Left ventricle end-systolic pressure
- LV ESV, Left ventricle end-systolic volume
- MACCE, Major adverse cardiovascular and cerebrovascular events
- MD, Mean difference
- MPG, Mitral pressure gradient
- MR, Mitral regurgitation
- MS, Mitral stenosis
- MVA, Mitral valve area
- Mitral stenosis
- Mitral valve surgery
- NOS, New castle Ottawa scale
- PMBV, percutaneous mitral balloon valvotomy
- Percutaneous balloon mitral valvotomy
- Percutaneous balloon mitral valvuloplasty
- SR, sinus rhythm
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Affiliation(s)
- Anan A Abu Rmilah
- William J. von Liebig Center for Transplantation and Clinical Regeneration Mayo Clinic, Rochester, MN, USA.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mahmoud A Tahboub
- William J. von Liebig Center for Transplantation and Clinical Regeneration Mayo Clinic, Rochester, MN, USA
| | - Adham K Alkurashi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Suhaib A Jaber
- Department of Internal Medicine, Al Hamadi Hospital, Riyadh, Saudi Arabia
| | | | - Deema Al-Souri
- Department of Internal Medicine, Med Star Washington Hospital Center, Washington DC, USA
| | - Bradley R Lewis
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Guy S Reeder
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Kasamsetty S, Suranagi M, Ramalingam R, Subramani K. Early Assessment of Left Atrial Appendicular Velocities in Patients Undergoing Balloon Mitral Valvuloplasty. JOURNAL OF THE INDIAN ACADEMY OF ECHOCARDIOGRAPHY & CARDIOVASCULAR IMAGING 2021. [DOI: 10.4103/jiae.jiae_65_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Simard T, Thangarasa T, Di Santo P, Labinaz A, Hibbert B. The balloon impasse sign in percutaneous transvenous mitral valvuloplasty. Oxf Med Case Reports 2020; 2020:omaa062. [PMID: 32793366 PMCID: PMC7416822 DOI: 10.1093/omcr/omaa062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 06/15/2020] [Accepted: 06/26/2020] [Indexed: 11/14/2022] Open
Abstract
Percutaneous transvenous mitral valvuloplasty (PTMV) is an established therapy for rheumatic mitral stenosis (MS). While the Wilkins score standardizes the description of valve anatomy and predicts successful PTMV, echocardiographic assessment has some limitations. The 'balloon impasse' sign is the inability to cross a stenotic valve with a deflated Inoue balloon. This sign was described in the 1990s as an indicator of severe subvalvular thickening (regardless of the echocardiographic findings), portending an increased risk of severe mitral regurgitation (MR) post-PTMV. Despite its implications for management, it has been seldom reported. A 57-year-old woman with symptomatic, severe MS and a Wilkins score of 7 underwent PTMV. The 'balloon impasse' sign was observed when attempting to cross the stenotic valve. When the balloon was fully inflated, severe MR was noted, and the patient required mitral valve replacement. This case demonstrates the continued importance of the 'balloon impasse' sign and its implications for the therapeutic efficacy of PTMV.
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Affiliation(s)
- Trevor Simard
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada.,Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Tharshika Thangarasa
- Faculty of Undergraduate Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada
| | - Pietro Di Santo
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada
| | - Alisha Labinaz
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada
| | - Benjamin Hibbert
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada.,Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON K1N 6N5, Canada
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Meta-Analysis of the Incidence, Prevalence, and Correlates of Atrial Fibrillation in Rheumatic Heart Disease. Glob Heart 2020; 15:38. [PMID: 32923332 PMCID: PMC7427678 DOI: 10.5334/gh.807] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objective: To estimate the incidence, prevalence, and correlates of atrial fibrillation (AF) in a global population with rheumatic heart disease (RHD). Methods: Bibliographic databases were searched to identify all published studies providing data on AF in patients with RHD. Random-effects meta-analysis method was used to pool estimates. Results: Eighty-three studies were included, reporting data from 75,637 participants with RHD in 42 countries. The global prevalence of AF in RHD was 32.8% (range: 4.3%–79.9%). It was higher in severe valvular disease (30.8% vs 20.7%, p = 0.009), in severe mitral valve disease compared to severe aortic disease (30.4% vs 6.3%, p = 0.038). The global cumulative incidence of AF in patients with RHD was 4.8%, 11.4%, 13.2%, and 30.8% at 1, 2, 5, and 10 years of follow-up, respectively. From comparison between patients with and without AF, AF was associated with increased age (mean difference [MD]: 9.5 years; 95% CI: 7.8–1.3), advanced heart failure (odds ratio [OR]: 4.4; 95% CI 2.1–9.3), tricuspid valve involvement (OR: 4.0; 95% CI: 3.0–5.3), history of thromboembolism (OR: 6.2; 95% CI: 3.4–11.4), highly sensitive C-reactive protein (MD: 5.5 mg/dL; 95% CI: 1.2–9.8), systolic pulmonary arterial pressure (MD: 3.6 mmHg; 95% CI: 0.8–6.3), right atrium pressure (MD: 1.5 mmHg; 95% CI: 1.0–2.0), and left atrium diameter (MD: 8.1 mm; 95% CI: 5.5–10.7). Conclusions: About one-third of patients with RHD have AF, with an incidence which almost triples every five years after diagnosis. Factors associated with AF include age, advanced heart failure, thromboembolism, and few cardiac hemodynamics parameters.
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8
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Hashimoto N, Arimoto T, Tamura H, Otaki Y, Kutsuzawa D, Watanabe M. Intracardiac echocardiography-guided simultaneous pulmonary vein isolation and percutaneous transvenous mitral commissurotomy. HeartRhythm Case Rep 2019; 6:40-43. [PMID: 31956501 PMCID: PMC6962748 DOI: 10.1016/j.hrcr.2019.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 09/04/2019] [Accepted: 10/14/2019] [Indexed: 11/28/2022] Open
Affiliation(s)
- Naoto Hashimoto
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Takanori Arimoto
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Harutoshi Tamura
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Yoichiro Otaki
- Department of Advanced Cardiovascular Therapeutics, Yamagata University School of Medicine, Yamagata, Japan
| | - Daisuke Kutsuzawa
- Department of Advanced Heart Rhythm Therapeutics, Yamagata University School of Medicine, Yamagata, Japan
| | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan.,Department of Advanced Cardiovascular Therapeutics, Yamagata University School of Medicine, Yamagata, Japan.,Department of Advanced Heart Rhythm Therapeutics, Yamagata University School of Medicine, Yamagata, Japan
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Abstract
PURPOSE OF REVIEW This review provides an update on rheumatic mitral stenosis. Acute rheumatic fever (RF), the sequela of group A β-hemolytic streptococcal infection, is the major etiology for mitral stenosis (MS). RECENT FINDINGS While the incidence of acute RF in the Western world had substantially declined over the past five decades, this trend is reversing due to immigration from non-industrialized countries where rheumatic heart disease (RHD) is higher. Pre-procedural evaluation for treatment of MS using a multimodality approach with 2D and 3D transthoracic and transesophageal echo, stress echo, cardiac CT scanning, and cardiac MRI as well as hemodynamic assessment by cardiac catheterization is discussed. The current methods of percutaneous mitral balloon commissurotomy (PMBC) and surgery are also discussed. New data on long-term follow-up after PMBC is also presented. For severe rheumatic MS, medical therapy is ineffective and definitive therapy entails PMBC in patients with suitable morphological mitral valve (MV) characteristics, or surgery. As procedural outcomes depend heavily on appropriate case selection, definitive imaging and interpretation are crucial. It is also important to understand the indications as well as morphological MV characteristics to identify the appropriate treatment with PMBC or surgery.
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Gajjala OR, Durgaprasad R, Velam V, Kayala SB, Kasala L. New integrated approach to percutaneous mitral valvuloplasty combining Wilkins score with commissural calcium score and commissural area ratio. Echocardiography 2017; 34:1284-1291. [DOI: 10.1111/echo.13635] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
| | | | | | | | - Latheef Kasala
- Department of Cardiology; SVIMS; Tirupati Andhra Pradesh India
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11
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Zairi I, Mzoughi K, Mroua F, Ben Moussa F, Amri I, Kammoun S, Fennira S, Kraiem S. [Results of percutaneous mitral balloon commissurotomy in pregnant women about 12 cases]. Ann Cardiol Angeiol (Paris) 2016; 67:18-24. [PMID: 27817848 DOI: 10.1016/j.ancard.2016.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 10/06/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Mitral stenosis (MS) is the most common valvular heart disease revealed or exacerbated by pregnancy. Percutaneous mitral balloon commissurotomy (PMC) is currently the treatment of choice when mitral valve morphology is favorable. AIM OF THE STUDY The purpose of this study is to evaluate the immediate, medium and long term results of percutaneous mitral balloon commissurotomy in pregnant women with a severe symptomatic mitral stenosis despite medical treatment. PATIENTS AND METHODS It is a retrospective study including 12 pregnant patients diagnosed with severe mitral stenosis and hospitalized in the cardiology department of Habib Thameur hospital between 1994 and 2014. A clinical and ultrasonographic monitoring was performed for over 15 years. RESULTS Mean patients age was 31.5±4.4 years. All patients were in NYHA class III or IV despite medical treatment. Mitral regurgitation was rated as moderate in four cases. Functional improvement was observed in all cases immediately after the procedure. Mitral valve area increased from 1.02±0.5cm2 averaged to 2±0.35cm2. Mitral regurgitation increased in three cases and appeared in two cases. All patients delivered at term. Newborns were all healthy. Two of them had a low birth weight. On the long term follow-up (95.58±64.1 months), five patients had mitral restenosis: two had a surgical valve replacement and three underwent a second percutaneous mitral balloon commissurotomy. CONCLUSION The effectiveness of the percutaneous mitral balloon commissurotomy is clearly documented by clinical and echocardiographic evaluation. In the case of pregnancy, the goal is not so much to obtain an optimal result but to cause hemodynamic improvement authorizing the continuation of pregnancy and childbirth.
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Affiliation(s)
- I Zairi
- Service de cardiologie, hôpital Habib Thameur, 3, rue A.-Ben-Ayed, 1089 Tunis Chebbi, Tunis, Tunisie.
| | - K Mzoughi
- Service de cardiologie, hôpital Habib Thameur, 3, rue A.-Ben-Ayed, 1089 Tunis Chebbi, Tunis, Tunisie
| | - F Mroua
- Service de cardiologie, hôpital Habib Thameur, 3, rue A.-Ben-Ayed, 1089 Tunis Chebbi, Tunis, Tunisie
| | - F Ben Moussa
- Service de cardiologie, hôpital Habib Thameur, 3, rue A.-Ben-Ayed, 1089 Tunis Chebbi, Tunis, Tunisie
| | - I Amri
- Service de cardiologie, hôpital Habib Thameur, 3, rue A.-Ben-Ayed, 1089 Tunis Chebbi, Tunis, Tunisie
| | - S Kammoun
- Service de cardiologie, hôpital Habib Thameur, 3, rue A.-Ben-Ayed, 1089 Tunis Chebbi, Tunis, Tunisie
| | - S Fennira
- Service de cardiologie, hôpital Habib Thameur, 3, rue A.-Ben-Ayed, 1089 Tunis Chebbi, Tunis, Tunisie
| | - S Kraiem
- Service de cardiologie, hôpital Habib Thameur, 3, rue A.-Ben-Ayed, 1089 Tunis Chebbi, Tunis, Tunisie
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12
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Abstract
PURPOSE OF REVIEW The purpose is to provide a broad overview of the current state of knowledge of pathogenesis, diagnosis, and management of rheumatic heart disease (RHD). RECENT FINDINGS Studies on pathogenesis of RHD have focused on autoimmunity because of molecular mimicry between the streptococcal M antigen α-helical coiled-coil structure and sarcomeric proteins such as myosin and tropomyosin. More recently, nonsarcomeric autoantigens, endothelial injury and the innate immune system have been proposed to play key roles in the pathogenesis of RHD. In the 2015 revised Jones Criteria, the importance of echocardiography and subclinical carditis in the diagnosis of acute rheumatic fever is highlighted. Experimental studies with targeted anti-inflammatory therapeutics have been largely unsuccessful and the only established treatment is still lifelong antibiotics. Efforts to improve patient selection and outcomes with percutaneous mitral balloon valvuloplasty are ongoing. With regard to surgical management, several groups have demonstrated excellent operative and midterm outcomes from valve repair as opposed to valve replacement. SUMMARY There are still many unanswered questions regarding RHD pathogenesis. The only accepted medical treatment is still long-term antibiotic therapy, whereas advances in mitral repair techniques have led to successful durable repairs being performed in high-volume, expert centers.
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Percutaneous transvenous mitral commissurotomy in mitral stenosis and left atrial appendage clot patients in special conditions: Hospital-based study. Indian Heart J 2016; 68:788-791. [PMID: 27931548 PMCID: PMC5143822 DOI: 10.1016/j.ihj.2016.04.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 04/22/2016] [Accepted: 04/25/2016] [Indexed: 12/03/2022] Open
Abstract
Background The percutaneous transvenous mitral commissurotomy is an important procedure for the treatment of mitral stenosis. A lot of mitral stenosis cases have left atrial appendage clot which precludes the patient from the benefit of this procedure. The aim of the study was to study the feasibility and safety of the procedure in a patient with appendage clot in the setup of certain urgent conditions. Method All cases of mitral stenosis with significant dyspnea and mitral valve area <1.5 cm2 with left atrial appendage clot and a condition which would preclude the patient from continuing on anticoagulation and needed urgent intervention were included in the study. From January 2011 to December 2013, twenty patients coming to Shahid Gangalal National Heart Centre, Kathmandu were selected for the procedure with conventional sampling technique. Informed written consent was obtained from the patients explaining all possible complications. The approval of the study was taken from the ethical committee of the hospital. Result Mean mitral valve area increased from 0.90 cm2 (SD ± 0.14) to 1.5 cm2 (SD ± 0.21) (p = 0.02). Left atrial mean pressure decreased from mean of 20 to 10 mmHg. Subjective improvement was reported in all. All of the patients had fulfilled criteria for successful PTMC. There was no mortality during hospital stay or in one-week follow-up period. There were no neurological complications or any need for emergency surgery. Conclusion The immediate result of percutaneous transvenous mitral commissurotomy in selected cases of mitral stenosis with left atrial appendage clot is safe and acceptable in certain urgent situations in experienced hands.
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14
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Beig JR, Tramboo NA, Rather HA, Hafeez I, Ananth V, Lone AA, Yaqoob I, Bhat IA, Ali M. Immediate effect of percutaneous transvenous mitral commissurotomy on atrial electromechanical delay and P-wave dispersion in patients with severe mitral stenosis. Indian Heart J 2015; 67 Suppl 2:S46-54. [PMID: 26688153 DOI: 10.1016/j.ihj.2015.10.375] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 09/30/2015] [Accepted: 10/15/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Mitral stenosis (MS) is associated with prolonged inter- and intra-atrial electromechanical delays and increased P-wave dispersion, which are markers of atrial fibrillation (AF) risk. This study was conducted to assess the immediate effect of successful percutaneous transvenous mitral commissurotomy (PTMC) on these parameters. METHODS This single center observational study included 25 patients with severe MS (aged 34.1 ± 7.1 years, with mean mitral valve area (MVA) of 0.74 ± 0.13 cm(2)), in sinus rhythm, who underwent successful PTMC at our hospital. P-wave dispersion (PWD) was calculated by subtracting minimum P-wave duration (P min) from maximum P-wave duration (Pmax), measured on a 12-lead surface ECG obtained from each patient in supine position at a paper speed of 50mm/s and 20mm/mV. Inter-atrial (AEMD), left intra-atrial (L-IAEMD), and right intra-atrial (R-IAEMD) electromechanical delays were measured on tissue Doppler imaging. PTMC was performed using the standard Inoue Balloon technique. All these parameters were evaluated and compared before and 24-48 h after PTMC. RESULTS Successful PTMC led to significant reduction in AEMD (p < 0.001), L-IAEMD (p < 0.001), and R-IAEMD (p < 0.001). There were no changes in Pmax, Pmin, and PWD immediately after PTMC. CONCLUSIONS Successful PTMC has a favorable early impact on inter- and intra-atrial electromechanical delays, which are considered as novel parameters of atrial electromechanical remodeling in MS patients. Prospective large-scale studies are required to confirm whether improvement in these markers translates into reduced long-term AF risk.
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Affiliation(s)
| | | | | | - Imran Hafeez
- Asst. Professor, Dept. of Cardiology, SKIMS, Srinagar, India
| | - Vijai Ananth
- DM Fellow, Dept. of Cardiology, SKIMS, Srinagar, India
| | - Ajaz A Lone
- Assoc. Professor, Dept. of Cardiology, SKIMS, Srinagar, India
| | - Irfan Yaqoob
- Senior Resident, Dept. of Cardiology, SKIMS, Srinagar, India
| | - Irfan A Bhat
- Senior Resident, Dept. of Cardiology, SKIMS, Srinagar, India
| | - Muzaffar Ali
- DM Fellow, Dept. of Cardiology, SKIMS, Srinagar, India
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15
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Mennuni MG, Zavalloni D, Presbitero P. Role, risk and benefit of interventional cardiology procedures during pregnancy. Interv Cardiol 2015. [DOI: 10.2217/ica.14.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Wunderlich NC, Beigel R, Siegel RJ. Management of Mitral Stenosis Using 2D and 3D Echo-Doppler Imaging. JACC Cardiovasc Imaging 2013; 6:1191-205. [DOI: 10.1016/j.jcmg.2013.07.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 07/03/2013] [Accepted: 07/18/2013] [Indexed: 10/26/2022]
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17
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Wunderlich NC, Beigel R, Siegel RJ. The role of echocardiography during mitral valve percutaneous interventions. Cardiol Clin 2013; 31:237-70. [PMID: 23743076 DOI: 10.1016/j.ccl.2013.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Transesophageal echocardiography is routinely used to guide percutaneous interventions involving the mitral valve. Mitral balloon valvuloplasty for rheumatic mitral valve stenosis (MS) was the first percutaneous intervention to gain wide acceptance. New techniques have been developed to treat degenerative and functional mitral regurgitation (MR) as well as paravalvular mitral leak (PVML). This review describes the use of echocardiography for transcatheter treatment of MS, MR, and PVML.
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Nair KKM, Pillai HS, Thajudeen A, Krishnamoorthy KM, Sivasubramonian S, Namboodiri N, Sasidharan B, Ganapathy S, Varaparambil A, Titus T, Tharakan J. Immediate and long-term results following balloon mitral valvotomy in patients with atrial fibrillation. Clin Cardiol 2012; 35:E35-9. [PMID: 23124930 DOI: 10.1002/clc.22068] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 09/28/2012] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The purpose of this study was to examine the influence of atrial fibrillation (AF) on the immediate and long-term outcome of patients undergoing balloon mitral valvotomy (BMV). HYPOTHESIS Patients with atrial fibrillation fair poorly after balloon mitral valvotomy. METHODS There were a total of 818 consecutive patients who underwent elective BMV in this institute from 1997 to 2003, with either double-lumen or triple-lumen BMV catheters included in the study. Of them, 95 were with AF. The clinical, echocardiographic, and hemodynamic data of these patients were compared with those of 723 patients in normal sinus rhythm (NSR). Immediate procedural results and long-term events were compared between the 2 study groups. RESULTS Patients with AF were older (39.9 ± 9.9 years vs 29.4 ± 10.1, P < 0.001) and presented more frequently with New York Heart Association (NYHA) class III-IV (53.7% vs 32.9%, P < 0.001), echocardiographic score >8 (47.4% vs 24.9%, P < 0.001), and with history of previous surgical commissurotomy (33.7% vs 11.5%, P < 0.001). In patients with AF, BMV resulted in inferior immediate and long-term outcomes, as reflected in a lesser post-BMV mitral valve area (1.3 ± 0.4 vs 1.6 ± 0.4 cm(2), P = 0.032) and higher event rate on follow-up. CONCLUSIONS Patients with AF were older, sicker, and had advanced rheumatic mitral valve disease. They had a higher incidence of stroke, new onset heart failure, and need for reinterventions on long-term follow-up. These patients need intense and more frequent follow-up.
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Affiliation(s)
- Krishna Kumar Mohanan Nair
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
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Fennira S, Antit S, Sioua S, Ellouze Y, Kamoun S, Mrabett K, Zairi I, Kraiem S. [Immediate results of repeat percutaneous mitral valvuloplasty]. Ann Cardiol Angeiol (Paris) 2012; 62:108-15. [PMID: 22959439 DOI: 10.1016/j.ancard.2012.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 08/07/2012] [Indexed: 11/30/2022]
Abstract
UNLABELLED 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.
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Affiliation(s)
- S Fennira
- Service de cardiologie, hôpital Habib Thameur, Tunis, Tunisie.
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20
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Sanati HR, Zahedmehr A, Shakerian F, Bakhshandeh H, Firoozi A, Kiani R, Sadeghpour A, Asgharnedjad E, Mikaelpour A, Nabati M. Percutaneous mitral valvuloplasty using echocardiographic intercommissural diameter as reference for balloon sizing: a randomized controlled trial. Clin Cardiol 2012; 35:749-54. [PMID: 22674095 DOI: 10.1002/clc.22013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 04/29/2012] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Percutaneous balloon mitral valvuloplasty is the preferred therapeutic strategy in patients with mitral stenosis, but it has shortcomings in a subset of patients. HYPOTHESIS A new method of balloon sizing through echocardiographic measurement of the intercommissural diameter would be safe and effective and lead to better outcomes. METHODS Eighty-six mitral-stenosis patients were randomly assigned to undergo balloon mitral valvuloplasty either with height-based balloon reference sizing (HBRS group, n = 43) or with balloons sized by the echocardiographic measurement of intercommissural diameter (EBRS group, n = 43). Postprocedural mitral valve area (MVA) and severity of mitral regurgitation (MR) were assessed via echocardiography and ventriculography. Intention-to-treat approach was applied for the statistical analysis. RESULTS Baseline characteristics were not different between the groups. The mean of the estimated balloon reference sizes was significantly higher in the HBRS patients than in the EBRS group (26.4 ± 0.92 mm, 95% confidence interval [CI]: 26.2-26.6 vs 24.5 ± 1.03 mm, 95% CI: 24.2-24.7, respectively; P = 0.006). Final MVAs were significantly larger in the EBRS group (1.5 ± 0.2 cm(2), 95% CI: 1.46-1.59 vs 1.4 ± 0.2 cm(2), 95% CI: 1.35-1.47, respectively; P = 0.01). The occurrence of new or aggravated MR was significantly lower in the EBRS group as assessed both by echocardiography (P = 0.04) and ventriculography (P = 0.05). Mitral regurgitation was aggravated in 13 (29.3%) patients in the HBRS group and in 5 (11.5%) patients in the EBRS group. CONCLUSIONS Percutaneous balloon mitral valvuloplasty via the Inoue technique using balloons sized by the echocardiographic measurement of the maximal commissural diameter is an effective and safe method that might lead to an acceptable increase in the MVA and significant decrease in the rate and severity of iatrogenic MR.
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Affiliation(s)
- Hamid Reza Sanati
- Cardiovascular Intervention Research Center, Rajaei Cardiovascular, Medical and Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Jorge E, Baptista R, Faria H, Calisto J, Matos V, Gonçalves L, Monteiro P, Providência LA. Mean pulmonary arterial pressure after percutaneous mitral valvuloplasty predicts long-term adverse outcomes. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2012. [DOI: 10.1016/j.repce.2011.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Mean pulmonary arterial pressure after percutaneous mitral valvuloplasty predicts long-term adverse outcomes. Rev Port Cardiol 2012; 31:19-25. [DOI: 10.1016/j.repc.2011.09.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 09/08/2011] [Indexed: 11/17/2022] Open
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New Scores for the Assessment of Mitral Stenosis Using Real-Time Three-Dimensional Echocardiography. CURRENT CARDIOVASCULAR IMAGING REPORTS 2011; 4:370-377. [PMID: 21949566 PMCID: PMC3165135 DOI: 10.1007/s12410-011-9099-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Nonsurgical management of patients with symptomatic mitral valve stenosis has been established as the therapeutic modality of choice for two decades. Catheter-based balloon dilation of the stenotic valvular area has been shown, at least, as effective as surgical interventions. Unfavorable results of catheter-based interventions are largely due to unfavorable morphology of the valve apparatus, particularly leaflets calcification and subvalvular apparatus involvement. A mitral valve score has been proposed in Boston, MA, about two decades ago, based on morphologic assessment of mitral valve apparatus by two-dimensional (2D) echocardiography to predict successful balloon dilation of the mitral valve. Several other scores have been developed in the following years in order to more successfully predict balloon dilatation outcome. However, all those scores were based on 2D echocardiography, which is limited by ability to distinguish calcification and subvalvular involvement. The introduction of new matrix-based ultrasound probe has allowed 3D echocardiography (3DE) to provide more detailed morphologic analysis of mitral valve apparatus including calcification and subvalvular involvement. Recently, a new 3DE scoring system has been proposed by our group, which represents an important leap into refinement of the use of echocardiography guiding mitral valve interventions.
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Pulmonary hypertension related to left-sided cardiac pathology. Pulm Med 2011; 2011:381787. [PMID: 21660234 PMCID: PMC3109401 DOI: 10.1155/2011/381787] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Revised: 04/02/2011] [Accepted: 04/02/2011] [Indexed: 12/28/2022] Open
Abstract
Pulmonary hypertension (PH) is the end result of a variety of diverse pathologic processes. The chronic elevation in pulmonary artery pressure often leads to right ventricular pressure overload and subsequent right ventricular failure. In patients with left-sided cardiac disease, PH is quite common and associated with increased morbidity and mortality. This article will review the literature as it pertains to the epidemiology, pathogenesis, and diagnosis of PH related to aortic valve disease, mitral valve disease, left ventricular systolic and diastolic dysfunction, and pulmonary veno-occlusive disease. Moreover, therapeutic strategies, which focus on treating the underlying cardiac pathology will be discussed.
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Liang KW, Fu YC, Lee WL, Wang KY, Ting CT, Jan SL, Lin WW, Lin IH. Comparisons of mechanical versus phase-array intracardiac echocardiography-assisted transseptal puncture in patients with dilated left atrium undergoing percutaneous transvenous mitral commissurotomy. J Chin Med Assoc 2010; 73:471-6. [PMID: 20875620 DOI: 10.1016/s1726-4901(10)70101-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 05/26/2010] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Percutaneous transvenous mitral commissurotomy (PTMC) is an effective treatment for mitral stenosis, but transseptal puncture carries a certain risk of complications. Our previous report has shown the effectiveness of phase-array intracardiac echocardiography (ICE)-guided transseptal puncture in patients with dilated left atrium undergoing PTMC. However, there are few reports comparing the new-generation mechanical versus phase-array ICE-guided transseptal puncture in PTMC. METHODS Between March 2007 and March 2008, 6 consecutive patients with symptomatic mitral stenosis with dilated left atrium (range, 4.1-6.1 cm) underwent transseptal puncture by mechanical ICE guidance in PTMC by the same experienced operator. The procedural, echocardiographic and clinical results were retrospectively retrieved and analyzed. In addition, phase-array ICE-guided transseptal cases (n = 7), which included consecutive cases from May to December 2008, were compared. RESULTS All 6 patients could have fossa ovalis visualized by ICE, and none of them had false transseptal puncture. Mechanical ICE provided a panoramic wider view of the interatrium septum, and offered better knowledge of the needle's geographic contact to the fossa ovalis than did the phase-array system. The fluoroscopic time of PTMC in the mechanical ICE-guided group (37 ± 9 minutes, n = 6) was similar (p = 0.465) to that of phase-array guidance (31 ± 15 minutes, n = 7). CONCLUSION Mechanical ICE is effective in guiding transseptal puncture in PTMC.
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Affiliation(s)
- Kae-Woei Liang
- Cardiovascular Center, Taichung Veterans General Hospital, #160 Section 3 Taichung Kang Road, Taichung, Taiwan
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Plasma levels of tumor necrosis factor-alpha and its receptors in patients with mitral stenosis and sinus rhythm undergoing percutaneous balloon valvuloplasty. Heart Vessels 2010; 25:131-7. [PMID: 20339974 DOI: 10.1007/s00380-009-1175-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2009] [Accepted: 05/21/2009] [Indexed: 10/19/2022]
Abstract
This study aimed to determine whether plasma levels of tumor necrosis factor-alpha (TNF-alpha) and soluble TNF receptor (sTNF-R) increases in rheumatic mitral stenosis (MS) patients with sinus rhythm and to examine the effect of percutaneous mitral balloon valvuloplasty (PMBV) on these parameters. Twenty-six patients with MS and sinus rhythm (study group, 20 female, mean age 33 +/- 8 years), who were scheduled for PMBV, and a well-matched control group consisting of 21 healthy volunteers (15 female, mean age 35 +/- 6 years) were enrolled in the study. Tumor necrosis factor-alpha and sTNF-R levels were compared between study patients and controls, and between peripheral and left atrium (LA) blood. Changes in TNF alpha and sTNF-R levels 24 h and 4 weeks after PMBV were analyzed. Significantly higher baseline TNF-alpha and sTNF-R levels were noted in the study group. In the study group, TNF-alpha and its receptors were also found to be higher in LA blood than in baseline peripheral blood. After PMBV, mitral valve area (MVA) increased and transmitral pressure gradient decreased significantly. At the 24th hour after PMBV, the TNF-alpha level decreased from 29.61 +/- 12.22 pg/ml to 22.42 +/- 8.81 pg/ml (P < 0.0001) and at the 4th week, from 22.42 +/- 8.81 pg/ml to 18.92 +/- 7.37 pg/ml (P < 0.0001). Similar reductions were observed in the sTNF-R level. Regression analysis between the difference in sTNF-R level measured 24 h after and before PMBV and the difference in MVA measured 24 h after and before PMBV showed a significant direct relationship between these variables. This study suggests that isolated rheumatic MS without atrial fibrillation is accompanied by increased TNF-alpha and sTNF-R level. The successful PMBV establishes a significant reduction in TNF-alpha and its receptors, probably due to improved postprocedural hemodynamic parameters.
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Chang WC, Lin IH, Ting CT, Liang KW. Balloon mitral commissurotomy for mitral stenosis after resolution of a large mobile left atrial thrombus by 2-year warfarin treatment. J Chin Med Assoc 2009; 72:646-9. [PMID: 20028646 DOI: 10.1016/s1726-4901(09)70448-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We report on a patient who was referred for percutaneous transvenous mitral commissurotomy for symptomatic mitral stenosis. However, transthoracic and transesophageal echocardiography both revealed a large mobile left atrial thrombus, occupying almost half of the left atrial body. Because the patient strongly declined surgical mitral treatment, he was administered warfarin for 2 years. Complete resolution of left atrial thrombus was confirmed by follow-up transesophageal echocardiography. Successful percutaneous transvenous mitral commissurotomy was undertaken without complications.
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Affiliation(s)
- Wei-Chun Chang
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan, R.O.C
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29
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Perk G, Lang RM, Garcia-Fernandez MA, Lodato J, Sugeng L, Lopez J, Knight BP, Messika-Zeitoun D, Shah S, Slater J, Brochet E, Varkey M, Hijazi Z, Marino N, Ruiz C, Kronzon I. Use of real time three-dimensional transesophageal echocardiography in intracardiac catheter based interventions. J Am Soc Echocardiogr 2009; 22:865-82. [PMID: 19647156 DOI: 10.1016/j.echo.2009.04.031] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Indexed: 12/25/2022]
Abstract
BACKGROUND Real-time three-dimensional (RT3D) echocardiography is a recently developed technique that is being increasingly used in echocardiography laboratories. Over the past several years, improvements in transducer technologies have allowed development of a full matrix-array transducer that allows acquisition of pyramidal-shaped data sets. These data sets can be processed online and offline to allow accurate evaluation of cardiac structures, volumes, and mass. More recently, a transesophageal transducer with RT3D capabilities has been developed. This allows acquisition of high-quality RT3D images on transesophageal echocardiography (TEE). Percutaneous catheter-based procedures have gained growing acceptance in the cardiac procedural armamentarium. Advances in technology and technical skills allow increasingly complex procedures to be performed using a catheter-based approach, thus obviating the need for open-heart surgery. METHODS The authors used RT3D TEE to guide 72 catheter-based cardiac interventions. The procedures included the occlusion of atrial septal defects or patent foramen ovales (n=25), percutaneous mitral valve repair (e-valve clipping; n=3), mitral balloon valvuloplasty for mitral stenosis (n=10), left atrial appendage obliteration (n=11), left atrial or pulmonary vein ablation for atrial fibrillation (n=5), percutaneous closures of prosthetic valve dehiscence (n=10), percutaneous aortic valve replacement (n=6), and percutaneous closures of ventricular septal defects (n=2). In this review, the authors describe their experience with this technique, the added value over multiplanar two-dimensional TEE, and the pitfalls that were encountered. RESULTS The main advantages found for the use RT3D TEE during catheter-based interventions were (1) the ability to visualize the entire lengths of intracardiac catheters, including the tips of all catheters and the balloons or devices they carry, along with a clear depiction of their positions in relation to other cardiac structures, and (2) the ability to ability to demonstrate certain structures in an "en face" view, which is not offered by any other currently available real-time imaging technique, enabling appreciation of the exact nature of the lesion that is undergoing intervention. CONCLUSION RT3D TEE is a powerful new imaging tool that may become the technique of choice and the standard of care for guidance of selected percutaneous catheter-based procedures.
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Affiliation(s)
- Gila Perk
- New York University School of Medicine, Interventional Cardiology Department, Lenox Hill Heart and Vascular Institute, New York, New York 10016, USA.
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Abstract
Mitral stenosis is a common disease that causes substantial morbidity worldwide. The disease is most prevalent in developing countries, but is increasingly being identified in an atypical form in developed countries. All treatments that increase valve area improve morbidity. Mortality improves with surgery; the benefit of percutaneous balloon valvuloplasty to mortality might be similar to that of surgery but needs further study. Percutaneous balloon valvuloplasty is the treatment of choice for patients in whom treatment is indicated, except for those with suboptimum valve morphology, and even these patients are sometimes treated with this procedure if surgery is not feasible or if surgical risk is prohibitive. We review the pathology, diagnosis, and treatment options for patients with mitral stenosis.
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Affiliation(s)
- Y Chandrashekhar
- Veterans Affairs Medical Center and University of Minnesota, Minneapolis, MN 55417, USA.
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31
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Iatrogenic Pericardial Effusion and Tamponade in the Percutaneous Intracardiac Intervention Era. JACC Cardiovasc Interv 2009; 2:705-17. [DOI: 10.1016/j.jcin.2009.04.019] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2009] [Accepted: 04/03/2009] [Indexed: 11/20/2022]
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Rifaie O, Esmat I, Abdel-Rahman M, Nammas W. Can a novel echocardiographic score better predict outcome after percutaneous balloon mitral valvuloplasty? Echocardiography 2009; 26:119-27. [PMID: 19207992 DOI: 10.1111/j.1540-8175.2008.00774.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE The assessment of patients with mitral stenosis before percutaneous balloon mitral valvuloplasty (PBMV) is crucial to predict outcome after the procedure. We tried to explore the prognostic power of a novel echocardiographic score to predict immediate postprocedural outcome in comparison to the standard score. METHODS We enrolled 50 consecutive patients with moderate to severe mitral stenosis admitted to undergo PBMV. For all patients, we assessed both the standard Massachusetts General Hospital (MGH) score and a novel score based on calcification (especially commissural) and subvalvular involvement. Patients underwent PBMV with the double balloon technique. Thereafter, patients were classified into two groups: group 1 (poor outcome) defined as no procedural success and/or increase of MR by more than 1 grade and group 2 (optimal outcome) defined as procedural success with increase of MR by 1 grade or less. RESULTS The total MGH score did not differ significantly between the two groups. However, among the individual parameters of the score, both calcification and subvalvular affection were significantly higher in group 1 versus group 2 (2.8 +/- 0.4 versus 1.7 +/- 0.8, and 2.4 +/- 0.5 versus 1.6 +/- 0.4, respectively, P < 0.01 for both). The total novel score and its two individual parameters (calcification and subvalvular involvement) were all significantly higher in group 1 versus group 2 (6 +/- 1.5 versus 2.9 +/- 1.9, 4.9 +/- 1.2 versus 2.4 +/- 1.5, 1.5 +/- 1.6 versus 0.5 +/- 0.9, respectively, P < 0.01 for all). Multivariate analysis demonstrated the novel score to be the only independent predictor of poor outcome. CONCLUSION The novel score is more reliable and correlates with outcome better than the standard score.
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Affiliation(s)
- Osama Rifaie
- Cardiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Tarka EA, Blitz LR, Herrmann HC. Hemodynamic effects and long-term outcome of percutaneous balloon valvuloplasty in patients with mitral stenosis and atrial fibrillation. Clin Cardiol 2009; 23:673-7. [PMID: 11016017 PMCID: PMC6654854 DOI: 10.1002/clc.4960230908] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The presence of atrial fibrillation (AF) has been identified as a predictor of a suboptimal result in some patients undergoing percutaneous balloon valvuloplasty in the treatment of symptomatic rheumatic mitral stenosis. HYPOTHESIS Atrial fibrillation adversely affects the short- and long-term outcome of patients with mitral stenosis undergoing percutaneous balloon valvuloplasty. METHODS A retrospective chart review of 104 consecutive patients with rheumatic mitral stenosis undergoing percutaneous balloon valvuloplasty was performed. A successful procedure was defined as a final mitral valve area > or = 1.5 cm2 and the absence of a complication. Endpoints included freedom from mitral valve replacement, death, and repeat balloon valvuloplasty at 5 years. RESULTS A successful procedure was obtained in 89% of patients with sinus rhythm and in 78% of patients with AF (p = NS). Patients in sinus rhythm had a greater cardiac output resulting in a larger final valve area than patients in AF (1.8 vs. 1.6 cm2, p < 0.05). Freedom from valve replacement, death, and repeat balloon valvuloplasty at 5 years was 75% for patients in AF and 76% for patients in sinus rhythm (p = NS). Lower postprocedure mitral regurgitation grade and absence of prior commissurotomy were the only independent predictors of event-free survival. CONCLUSIONS Patients with mitral stenosis and AF have lower cardiac outputs and gradients than patients with sinus rhythm, despite similar valve areas. The long-term outcome of balloon valvuloplasty is independent of the initial cardiac rhythm.
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Affiliation(s)
- E A Tarka
- Department of Medicine, University of Pennsylvania Medical Center, Philadelphia 19104, USA
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Lau KW, Ding ZP, Hung JS. Percutaneous transvenous mitral commissurotomy versus surgical commissurotomy in the treatment of mitral stenosis. Clin Cardiol 2009; 20:99-106. [PMID: 9034637 PMCID: PMC6656037 DOI: 10.1002/clc.4960200204] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
There is no doubt that percutaneous transvenous mitral commissurotomy (PTMC) in experienced centers is associated with a low risk of major complications and yields excellent immediate and long-term outcome. Although previous observational studies on both PTMC and surgical commissurotomy have indicated similar outcome between the two treatment strategies in terms of valve area improvement and risk of major complication (death, thromboembolism and significant resultant mitral regurgitation), it was not until recently that several prospective randomized trials comparing the two procedures and involving > 470 patients with favorable valve characteristics (pliable, noncalcified valve with mild subvalvular disease and no or mild mitral regurgitation), have confirmed that PTMC is indeed just as, if not more, effective as surgical commissurotomy. The late restenosis rate at up to 3-year follow-up appears comparable. Furthermore, PTMC has other additional benefits. It is nontraumatic, may be repeated without additional risk, and has been shown to be an extremely useful and efficacious palliative tool in those with end-stage mitral stenosis or with unfavorable valve anatomy who refuse surgery, and in certain subset of patients at high surgical risk because of medical comorbidities.
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Affiliation(s)
- K W Lau
- Singapore Heart Centre, Singapore
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Oukerraj L, El houari T, El Haitem N, Bennani R, Fellat N, Fikri N, Mesbahi R, Benomar M. Urgent balloon mitral valvotomy in acute refractory pulmonary edema. Int J Cardiol 2008; 129:444-6. [PMID: 17651839 DOI: 10.1016/j.ijcard.2007.06.073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2007] [Accepted: 06/30/2007] [Indexed: 11/30/2022]
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Liang KW, Fu YC, Lee WL, Liu TJ, Wang KY, Hsueh CW, Lin IH, Chen YT, Ting CT. Intra-cardiac echocardiography guided trans-septal puncture in patients with dilated left atrium undergoing percutaneous transvenous mitral commissurotomy. Int J Cardiol 2007; 117:418-21. [PMID: 16899314 DOI: 10.1016/j.ijcard.2006.05.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2006] [Accepted: 05/26/2006] [Indexed: 12/01/2022]
Abstract
Percutaneous transvenous mitral commissurotomy (PTMC) is an effective treatment for mitral stenosis, but trans-septal puncture carries a certain risk of complications. There have been few reports on phase-array intra-cardiac echocardiography (ICE) guidance in trans-septal puncture for PTMC, especially in patients with dilated left atrium or distorted anatomy. Herein, we report our preliminary experience with ICE-guided trans-septal puncture in patients with dilated left atrium (>or=5.5 cm) who underwent PTMC. From June 2005 to March 2006, there were nine consecutive patients with symptomatic mitral stenosis and left atrium size larger than 5.5 cm who underwent trans-septal puncture for PTMC with the ICE guidance in this institution by a same operator. The procedural and catheterization results were analyzed. Using ICE guidance, the success rate for trans-septal puncture was 100% for all patients with dilated left atrium (>or=5.5 cm). The trans-septal procedures were free of major and minor complications and the patients were not exposed to contrast medium. Mitral valve area increased significantly from 1.0+/-0.2 cm(2) to 1.9+/-0.2 cm(2). Our preliminary result showed that ICE safely and effectively guided trans-septal puncture for PTMC in patients with dilated left atrium (>or=5.5 cm), thus eliminating contrast medium usage and avoiding unnecessary longer X-ray exposure.
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Kim MJ, Song JK, Song JM, Kang DH, Kim YH, Lee CW, Hong MK, Kim JJ, Park SW, Park SJ. Long-Term Outcomes of Significant Mitral Regurgitation After Percutaneous Mitral Valvuloplasty. Circulation 2006; 114:2815-22. [PMID: 17159061 DOI: 10.1161/circulationaha.106.658088] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mild commissural mitral regurgitation (MR) is associated with significantly higher restenosis-free survival after percutaneous mitral valvuloplasty (PMV), which suggests that different mechanisms of significant MR after PMV may have different clinical courses. We therefore analyzed long-term prognostic factors of significant MR after PMV. METHODS AND RESULTS Echocardiographic and clinical follow-up data on 380 patients were analyzed (286 women, mean age 44+/-11 years) who underwent PMV with the Inoue balloon technique between 1995 and 2000. Significant MR developed in 47 patients (12.4%). The survival rate at 8 years was 96+/-3% and 98+/-10% in patients with and without significant MR, respectively (P=0.084). The most frequent mechanism was commissural MR, or MR that originated at the site of successful commissurotomy, which occurred in 27 of 47 patients (57%), whereas noncommissural MR occurred in 20 (43%) patients, 12 (26%) with subvalvular damage resulting in chordae rupture and flail motion and 8 (17%) with leaflet laceration. The 8-year event-free survival rate was significantly lower in patients with significant MR than in those without (47+/-8% versus 83+/-3%, P<0.001) and was significantly higher in patients with commissural versus noncommissural MR (63+/-11% versus 29+/-11%, P<0.001). Of the 47 patients with significant MR, who were followed up for 74+/-29 months, 19 patients (40%) underwent mitral valve replacement, and 28 patients (60%) received medical treatment only. Patients with commissural MR had a significantly lower rate of mitral valve replacement than patients with noncommissural MR (15% versus 70%, P<0.001). Multivariate analysis showed that atrial fibrillation (odds ratio, 7.4; 95% CI, 1.1 to 56.4; P=0.038), mean mitral gradient immediately after PMV (odds ratio, 1.5; 95% CI, 1.1 to 2.0; P=0.009), and the mechanism of MR (odds ratio, 16.7; 95% CI, 2.3 to 122.2; P=0.005) were independent factors associated with mitral valve replacement. CONCLUSIONS Clinical outcome of patients with significant MR after PMV varied according to MR mechanism and the adequacy of hemodynamic improvement, which is easily assessed by echocardiography immediately after PMV.
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Affiliation(s)
- Mi-Jeong Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Poongnap-dong Songpa-ku, Seoul 138-736 South Korea
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Livingstone RS, Chandy S, Peace BST, George P, John B, Pati P. Audit of radiation dose during balloon mitral valvuloplasty procedure. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2006; 26:397-404. [PMID: 17146124 DOI: 10.1088/0952-4746/26/4/004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Radiation doses to patients during cardiological procedures are of concern in the present day scenario. This study was intended to audit the radiation dose imparted to patients during the balloon mitral valvuloplasty (BMV) procedure. Thirty seven patients who underwent the BMV procedure performed using two dedicated cardiovascular machines were included in the study. The radiation doses imparted to patients were measured using a dose area product (DAP) meter. The mean DAP value for patients who underwent the BMV procedure from one machine was 19.16 Gy cm(2) and from the other was 21.19 Gy cm(2). Optimisation of exposure parameters and radiation doses was possible for one machine with the use of appropriate copper filters and optimised exposure parameters, and the mean DAP value after optimisation was 9.36 Gy cm(2).
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Topaloglu S, Aras D, Ergun K, Geyik B, Ayaz S, Cay S, Cagirci G, Tufekcioglu O, Korkmaz S. Plasma level of soluble P-selectin in patients with rheumatic mitral stenosis and sinus rhythm undergoing percutaneous mitral balloon valvuloplasty. J Thromb Thrombolysis 2006; 23:199-204. [PMID: 17131174 DOI: 10.1007/s11239-006-9039-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2006] [Accepted: 10/20/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To determine whether plasma level of soluble P-selectin (sP-selectin) increases in rheumatic mitral stenosis (MS) patients with sinus rhythm, who have scheduled for percutaneous mitral balloon valvuloplasty (PMBV), and to examine the effect of PMBV on sP-selectin level. METHODS Twenty-six patients with MS and sinus rhythm (study group, 20 female, mean age 33 +/- 8 years) and a well-matched control group composed of 21 healthy volunteers (15 female, mean age 35 +/- 6 years) were enrolled in the study. In each patient left atrial (LA) thrombus was excluded by transesophageal echocardiography. sP-selectin levels were compared between study patients and controls, and between peripheral and LA blood. Changes in sP-selectin level 24 h and 4 weeks after PMBV were also analyzed. RESULTS A significantly higher basal sP-selectin level was noted in study group. After PMBV, the mitral valve area (MVA) increased and the transmitral mean gradient decreased significantly. At 24th hour after PMBV, sP-selectin level decreased from 1080.38 +/- 143.87 ng/ml to 960.00 +/- 103.26 ng/ml (p < 0.0001) and at 4th-week follow-up it was decreased from 960.00 +/- 103.26 ng/ml to 879.61 +/- 98.16 ng/ml (p < 0.0001). No significant difference was found between peripheral and LA blood regarding the sP-selectin level. Correlation analysis between the difference in MVA measured 24-hour after and before PMBV and the difference in sP-selectin level measured 24-hour after and before PMBV showed a significant direct relationship between these variables. CONCLUSION This study suggests that in patients with MS and sinus rhythm sP-selectin level increases probably due to turbulent flow across the stenotic valve. After PMBV sP-selectin shows a progessive decline, which is directly correlated with the increase in MVA.
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Affiliation(s)
- Serkan Topaloglu
- Department of Cardiology, Türkiye Yuksek Ihtisas Hospital, Akpinar Mah. 23. Cad. No: 10/22 Dikmen, Cankaya, 06450 Ankara, Turkey.
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Esteves CA, Munoz JS, Braga S, Andrade J, Meneghelo Z, Gomes N, Maldonado M, Esteves V, Sepetiba R, Sousa JE, Palacios IF. Immediate and long-term follow-up of percutaneous balloon mitral valvuloplasty in pregnant patients with rheumatic mitral stenosis. Am J Cardiol 2006; 98:812-6. [PMID: 16950192 DOI: 10.1016/j.amjcard.2006.03.068] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2005] [Revised: 03/30/2006] [Accepted: 03/30/2006] [Indexed: 11/26/2022]
Abstract
Percutaneous mitral balloon valvuloplasty (PMV) can be performed during pregnancy without significant maternal risk or fetal morbidity or mortality. However, little is known about long-term follow-up results after PMV in populations of pregnant women. Thus, the present study was undertaken to determine the immediate and long-term outcomes after PMV in a large cohort of pregnant patients with severe mitral stenosis. The patient population consisted of 71 consecutive pregnant women with severe rheumatic mitral stenosis admitted to the hospital with severe congestive heart failure (New York Heart Association class III and IV) for PMV. All patients underwent clinical and obstetric evaluations, electrocardiography, and 2-dimensional and Doppler echocardiography. PMV was successful in all patients, resulting in a significant increase in mitral valve area from 0.9 +/- 0.2 to 2.0 +/- 0.3 cm2 (p <0.001). At the end of pregnancy, 98% of the patients were in New York Heart Association functional class I or II. At a mean follow-up of 44 +/- 31 months, the total event-free survival rate was 54%. The mean gestational age at delivery time was 38 +/- 1 weeks. Preterm deliveries occurred in 9 patients (13%), including 2 twin pregnancies. The remaining 66 of 75 newborns (88%) had normal weight (mean 2.8 +/- 0.6 kg) at delivery. At long-term follow-up of 44 +/- 31 months after birth, the 66 children exhibited normal growth and development and did not show any clinical abnormalities. In conclusion, PMV is safe and effective, has a low morbidity and mortality rate for the mother and the fetus, and has favorable long-term results in pregnant women with rheumatic mitral stenosis in New York Heart Association functional class III or IV.
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Sanchez PL, Rodriguez-Alemparte M, Inglessis I, Palacios IF. The Impact of Age in the Immediate and Long-Term Outcomes of Percutaneous Mitral Balloon Valvuloplasty. J Interv Cardiol 2005; 18:217-25. [PMID: 16115149 DOI: 10.1111/j.1540-8183.2005.00045.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Differences in age, clinical characteristics, and valve morphology may account for controversial results of percutaneous mitral balloon valvuloplasty (PMV). METHODS We have previously reported the immediate and long-term clinical follow-up (50 +/- 45 months) of 879 patients who underwent PMV at the Massachusetts General Hospital. In the present study, we used this database to determine the impact of age in the immediate and long-term outcome of PMV. For purpose of analysis, these patients were divided into four age groups: group 1 (< or =35 years), group 2 (36-55 years), group 3 (56-75 years), and group 4 (>75 years). RESULTS The incidence of atrial fibrillation, calcified valves under fluoroscopy, higher echocardiographic score, New York Heart Association (NYHA) class IV and pre-PMV mitral regurgitation (MR) increased with patient's age. As patients became older, a lower post-PMV mitral valve area (2.1 +/- 0.7, 2.0 +/- 0.6, 1.8 +/- 0.6, and 1.6 +/- 0.6; P < 0.0001) and progressive decrease in procedural success (81.4%, 80.5%, 65.3%, and 53%; P < 0.0001) were observed. Younger age was identified as an independent predictor of PMV success by multiple stepwise logistic regression (odds ratio [OR]: 3.33; confidence interval [CI]: 1.41-7.69, P = 0.006). Furthermore, age was identified as an independent predictor of long-term events by Cox regression analysis (risk ratio [RR]: 1.02; CI: 1.01-1.03, P < 0.00001). However, the effect of age seemed to be blunted by the morphology of the valve at follow-up, as patients with echocardiogram score >8 in groups 2, 3, and 4 presented similar combined event-free survival (death, mitral valve replacement, or redo PMV). CONCLUSION Age is an important predictor of immediate and long-term outcomes after PMV, particularly in patients with optimal mitral valve morphology. (
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Affiliation(s)
- Pedro L Sanchez
- Cardiac Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Chen MC, Chang HW, Wu CJ, Yang CH, Hung WC, Yeh KH, Fu M. Percutaneous Transluminal Mitral Valvuloplasty Reduces Circulating Soluble CD40 Ligand in Rheumatic Mitral Stenosis. Chest 2005; 128:36-41. [PMID: 16002913 DOI: 10.1378/chest.128.1.36] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Recent data suggest that the pathogenesis of vascular inflammation and thrombosis involves CD40 ligand (CD40L), which is mostly derived from platelets. Previous studies have demonstrated that platelet activation occurs in peripheral blood of patients with rheumatic mitral stenosis (MS). However, in patients with MS, the plasma level of soluble CD40L has never been investigated. METHODS AND RESULTS Seventeen patients with symptomatic MS undergoing percutaneous transluminal mitral valvuloplasty were studied (group 1, 11 patients in permanent atrial fibrillation and 6 patients in sinus rhythm). Solid-phase, sandwich enzyme-linked immunosorbent assay determined the plasma levels of soluble CD40L in the femoral vein and artery, and right and left atria before valvuloplasty, and those in the peripheral venous blood obtained 10 min after valvuloplasty, and at the 4-week follow-up after valvuloplasty. The Doppler pressure half-time method was used to calculate the mitral valve area. Additionally, plasma concentrations of soluble CD40L in the peripheral venous blood obtained from 17 control patients were measured (including nine healthy volunteers in sinus rhythm [group 2] and eight patients in permanent lone atrial fibrillation [group 3]). Plasma levels of soluble CD40L were significantly elevated in group 1 patients (437.6 +/- 370.2 pg/mL) [mean +/- SD] compared with group 2 (203.8 +/- 218.0 pg/mL) and group 3 patients (173.5 +/- 105.0 pg/mL) [p < 0.05]. The area of mitral valve increased significantly after valvuloplasty (1.10 +/- 0.20 cm(2) vs 1.47 +/- 0.29 cm(2), p < 0.0001). The mean left atrial pressure fell significantly and immediately after valvuloplasty (22.8 +/- 4.9 mm Hg vs 17.6 +/- 5.5 mm Hg, p = 0.0004). The peripheral venous plasma levels of soluble CD40L obtained before valvuloplasty significantly fell after valvuloplasty (before, 437.6 +/- 370.2 pg/mL; vs 10 min after, 215.4 +/- 113.9 pg/mL; vs 4 weeks after, 217.5 +/- 111.9 pg/mL; p < 0.02). CONCLUSIONS Patients with moderate-to-severe MS had higher venous plasma levels of soluble CD40L than healthy volunteers or patients with lone atrial fibrillation. Additionally, the elevated venous plasma levels of soluble CD40L fell significantly following valvuloplasty.
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Affiliation(s)
- Mien-Cheng Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, 123Ta Pei Rd, Niao Sung Hsiang, Kaohsiung Hsien 83301, Taiwan, ROC.
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Chen MC, Wu CJ, Chang HW, Yip HK, Chen YH, Cheng CI, Chai HT. Mechanism of reducing platelet activity by percutaneous transluminal mitral valvuloplasty in patients with rheumatic mitral stenosis. Chest 2004; 125:1629-34. [PMID: 15136369 DOI: 10.1378/chest.125.5.1629] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Previous studies have demonstrated that platelet activity significantly decreased after optimal percutaneous transluminal mitral valvuloplasty (PTMV) in patients with rheumatic mitral stenosis (MS). However, the mechanism of reducing platelet activity by valvuloplasty remains unclear. METHODS AND RESULTS We studied 19 patients with symptomatic MS who were undergoing PTMV. The fractions of unstimulated platelets expressing P-selectin in the venous blood obtained before, and at the 1-week and 4-week follow-ups after PTMV were determined by flow cytometry. The mitral valve areas, measured before and at the 1-week follow-up after PTMV, were calculated by means of the Doppler pressure half-time method. The mean (+/- SD) area of the mitral valve increased significantly after PTMV (1.05 +/- 0.17 vs 1.44 +/- 0.27 cm2, respectively; p < 0.0001). The mean left atrial area was reduced in size significantly after PTMV (36.6 +/- 11.4 vs 33.9 +/- 13.4 cm2, respectively; p < 0.05). The mean left atrial pressure (23.3 +/- 5.1 vs 18.0 +/- 5.8 mm Hg, respectively; p < 0.0001) and the mean pulmonary arterial pressure (31.4 +/- 7.8 vs 26.1 +/- 7.7 mm Hg, respectively; p < 0.0001) fell significantly after PTMV. The fraction of platelets expressing P-selectin in the venous blood fell significantly after PTMV (before PTMV, 4.7 +/- 2.4%; 1 week after PTMV, 2.2 +/- 2.1%; 4 weeks after PTMV, 2.0 +/- 1.7%; p < 0.0001). Correlation analysis demonstrated that there was a significantly direct relationship between the magnitude of increase in mitral valve area and the magnitude of decrease in the fraction of platelets expressing P-selectin in the venous blood 4 weeks after PTMV (p = 0.0013; r = 0.682). However, there was no significant correlation between the magnitude of decrease in the fraction of platelets expressing P-selectin in the venous blood and the magnitude of decrease in the left atrial area, the decrease in left atrial pressure, or the decrease in the pulmonary artery pressure after PTMV. CONCLUSIONS In patients with moderate-to-severe MS, increased platelet activation fell significantly after PTMV. It was the increase in mitral valve area by PTMV, instead of hemodynamic and echocardiographic factors, that accounted for the decrease in the fraction of venous platelets expressing P-selectin after PTMV.
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Affiliation(s)
- Mien-Cheng Chen
- Department of Internal Medicine, Division of Cardiology, Chang Gung Memorial Hospital, Kaohsiung, Taiwan, ROC.
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Chen MC, Chang HW, Juang SS, Yip HK, Wu CJ. Increased Plasma Levels of Soluble P-Selectin in Rheumatic Mitral Stenosis. Chest 2004. [DOI: 10.1016/s0012-3692(15)32894-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Chen MC, Chang HW, Juang SS, Yip HK, Wu CJ, Yu TH, Cheng CI. Percutaneous Transluminal Mitral Valvuloplasty Reduces Circulating Vascular Cell Adhesion Molecule-1 in Rheumatic Mitral Stenosis. Chest 2004; 125:1213-7. [PMID: 15078727 DOI: 10.1378/chest.125.4.1213] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The circulating levels of adhesion molecules, such as vascular cell adhesion molecule-1 (VCAM-1) and intercellular adhesion molecule-1 (ICAM-1), have been demonstrated to be elevated in patients with rheumatic mitral stenosis (MS). However, the impact of percutaneous transluminal mitral valvuloplasty (PTMV) on the elevated circulating levels of VCAM-1 and ICAM-1 in patients with MS has never been investigated. METHODS and results: A total of 19 patients with symptomatic MS undergoing PTMV were studied (group 1) [15 patients in chronic atrial fibrillation, and 4 patients in sinus rhythm]. The plasma levels of soluble VCAM-1 and ICAM-1 in the femoral vein and artery, and right and left atria before PTMV, and those in the peripheral venous blood at the 1-week and 4-week follow-ups after PTMV were determined by solid-phase sandwich enzyme-linked immunosorbent assay. The mitral valve area was calculated by means of the Doppler pressure half-time method. In addition, we measured plasma concentrations of soluble VCAM-1 and ICAM-1 in the peripheral venous blood samples obtained from 22 control patients (including 14 healthy volunteers in sinus rhythm [group 2] and 8 patients in chronic lone atrial fibrillation [group 3]). The plasma level of soluble VCAM-1 was significantly elevated in group 1 patients (1,205.4 +/- 462.4 ng/mL [mean +/- SD]) compared with group 2 (580.9 +/- 208.0 ng/mL) and group 3 patients (716.4 +/- 221.6 ng/mL) [p < 0.0001]. In group 1 patients, the plasma levels of soluble VCAM-1 and ICAM-1 in the left atrium did not differ from those in the right atrium, femoral vein, or femoral artery (p = 0.668 for VCAM-1, and p = 0.232 for ICAM-1). The area of mitral valve increased significantly after PTMV (1.08 +/- 0.14 cm(2) vs 1.48 +/- 0.33 cm(2), p < 0.0001). The mean left atrial pressure fell significantly after PTMV (22.9 +/- 5.2 mm Hg vs 17.7 +/- 6.0 mm Hg, p < 0.0001). The peripheral venous plasma level of soluble VCAM-1 obtained before PTMV fell significantly after PTMV (before, 1,205.4 +/- 462.4 ng/mL; 1 week after PTMV, 915.7 +/- 280.2 ng/mL; 4 weeks after PTMV, 859.0 +/- 298.7 ng/mL; p < 0.0001). CONCLUSIONS In patients with moderate-to-severe MS, the venous plasma level of soluble VCAM-1 fell significantly after PTMV, and the elevated plasma soluble VCAM-1 concentration was associated with hemodynamic abnormality rather than with rheumatic activity.
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Affiliation(s)
- Mien-Cheng Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Hsien, Taiwan, ROC.
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Liu TJ, Hsueh CW, Lee WL, Lai HC, Wang KY, Ting CT. Conversion of rheumatic atrial fibrillation by amiodarone after percutaneous balloon mitral commissurotomy. Am J Cardiol 2003; 92:1244-6. [PMID: 14609612 DOI: 10.1016/j.amjcard.2003.07.045] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Amiodarone, used in conjunction with percutaneous balloon mitral commissurotomy, can safely convert rheumatic atrial fibrillation in 38% of patients compared with 0% in those without it. However, whether this treatment exerts long-term benefits on prognosis awaits further investigation.
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Affiliation(s)
- Tsun-Jui Liu
- Division of Cardiology, Department of Medicine, Taichung Veterans General Hospital, Taipei, Taiwan.
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Bhatla N, Lal S, Behera G, Kriplani A, Mittal S, Agarwal N, Talwar KK. Cardiac disease in pregnancy. Int J Gynaecol Obstet 2003; 82:153-9. [PMID: 12873775 DOI: 10.1016/s0020-7292(03)00159-0] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To evaluate the maternal and fetal outcome of pregnancies complicated by cardiac disease in a developing country. METHODS A retrospective analysis was carried out of 207 pregnancies in women with cardiac disease who delivered at >or=28 weeks of gestation from June 1994 through December 2000 at a tertiary care center. RESULTS Rheumatic heart disease (n=183, 88%) with isolated mitral stenosis (n=71) was the predominant cardiac problem. Septal defects were the most common form of congenital heart disease (n=24). In 28 (13.52%) women, the diagnosis of cardiac disease was made during pregnancy. Cardiac complications were noted in 62 (29.95%) and fetal complications in 42 (20.28%) pregnancies. Patients in NYHA class I/II (n=175, 84.54%) had fewer maternal complications and their babies had a higher birth weight than those in NYHA class III/IV (n=32, 15.45%). Cardiac intervention was performed prior to pregnancy in 111 (60.65%) patients with rheumatic heart disease: PTMC/CMV in 73 and valve replacement (VR) in 38. Maternal and fetal outcome was better in patients with prosthetic valves (n=38) and the majority (97.4%) of them remained in NYHA class I/II. Cardiac intervention was safely carried out during pregnancy in 10 women (PTMC in 7, CMV in l, and VR in 2). One of them developed congestive cardiac failure during labor. None of the newborns of the 41 women who had received anticoagulants had any congenital malformation. CONCLUSIONS Rheumatic heart disease was the predominant type. Patients in NYHA class I/II had a better maternal and fetal outcome than those in NYHA class III/IV. Surgical correction of the cardiac lesion prior to pregnancy was associated with better pregnancy outcome. Pregnant women with prosthetic valves tolerated pregnancy well.
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MESH Headings
- Adolescent
- Adult
- Cardiovascular Agents/therapeutic use
- Female
- Heart Defects, Congenital/therapy
- Heart Diseases/diagnosis
- Heart Diseases/drug therapy
- Heart Diseases/epidemiology
- Heart Diseases/surgery
- Heart Diseases/therapy
- Heart Valve Prosthesis
- Humans
- India/epidemiology
- Infant, Low Birth Weight
- Infant, Newborn
- Labor, Obstetric
- Pregnancy
- Pregnancy Complications, Cardiovascular/diagnosis
- Pregnancy Complications, Cardiovascular/drug therapy
- Pregnancy Complications, Cardiovascular/epidemiology
- Pregnancy Complications, Cardiovascular/surgery
- Pregnancy Complications, Cardiovascular/therapy
- Pregnancy Outcome
- Pregnancy, High-Risk
- Retrospective Studies
- Rheumatic Heart Disease/therapy
- Risk Assessment
- Severity of Illness Index
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Affiliation(s)
- N Bhatla
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India.
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Chiang CW, Hsu LA, Chu PH, Ho WJ, Lo HS, Chang CC. Feasibility of simplifying balloon mitral valvuloplasty by obviating left-sided cardiac catheterization using on-line guidance with transesophageal echocardiography. Chest 2003; 123:1957-63. [PMID: 12796174 DOI: 10.1378/chest.123.6.1957] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES The purpose of this study was to evaluate the feasibility of simplifying balloon mitral valvuloplasty through the obviation of left-sided cardiac catheterization using on-line guidance with transesophageal echocardiography in patients with mitral stenosis. SETTING A tertiary care medical center DESIGN Patients who were eligible for balloon mitral valvuloplasty were enrolled into the study if they had no evidence of ischemic heart disease. Sixty-six patients (50 women and 16 men) met the criteria. Balloon mitral valvuloplasty was performed through right-sided cardiac catheterization using adjunctive on-line guidance with transesophageal echocardiography. Left-sided catheterization was obviated. MEASUREMENT AND RESULTS Balloon mitral valvuloplasty was smoothly performed in all patients. Successful dilatation (postprocedural mitral orifice area, > 1.5 cm(2); or increment in mitral orifice area, >or= 50%) was achieved in 50 patients (75.8%). The mean (+/- SD) mitral orifice area increased from 1.08 +/- 0.23 cm(2) to 1.68 +/- 0.39 cm(2) (p = 0.0000). There were no in-hospital deaths, no patients with cardiac tamponade, or complications necessitating an emergency cardiac operation. The mean fluoroscopy time was 7.6 +/- 3.9 min, and the total procedure time was 50.2 +/- 15.0 min. CONCLUSION It is feasible and safe to simplify balloon mitral valvuloplasty by obviating left-sided cardiac catheterization in selected patients with mitral stenosis using adjunctive on-line guidance with transesophageal echocardiography.
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Affiliation(s)
- Cheng-Wen Chiang
- Department of Internal Medicine, Cathay General Hospital, Taipei, Taiwan, Republic of China.
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Krishnamoorthy KM, Radhakrishnan S, Shrivastava S. Natural history and predictors of moderate mitral regurgitation following balloon mitral valvuloplasty using Inoue balloon. Int J Cardiol 2003; 87:31-6. [PMID: 12468052 DOI: 10.1016/s0167-5273(02)00205-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND We studied the predictors and natural history of moderate mitral regurgitation following valvuloplasty using Inoue balloon since it has not been well documented in a large series. METHODS Balloon mitral valvuloplasty was performed in 590 consecutive patients with severe mitral stenosis with mitral regurgitation of mild or lesser grade. Echocardiography and haemodynamics of patients who developed moderate mitral regurgitation were compared with those who did not. They were followed-up. Factors that predicted the development of moderate regurgitation were studied. RESULTS 21 patients (3.5%) developed moderate regurgitation (identified by auscultation, haemodynamics, angiography and colour flow mapping). They were managed conservatively. At 3 months, regurgitation decreased in severity to mild grade in 12 patients. At 1 year, it was trivial in 5, mild in 11 and remained moderate in 5. There was progressive symptomatic improvement. No clinical, echocardiographic, hemodynamic or procedural variables could predict the development of moderate mitral regurgitation. CONCLUSIONS Patients with moderate regurgitation after mitral valvuloplasty show gradual improvement in regurgitation and symptoms. There were no factors-clinical, echocardiographic, hemodynamic or procedural-that predicted the occurrence of moderate MR after BMV.
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Affiliation(s)
- K M Krishnamoorthy
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India.
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Tsuji T, Ikari Y, Tamura T, Wanibuchi Y, Hara K. Pathologic analysis of restenosis following percutaneous transluminal mitral commissurotomy. Catheter Cardiovasc Interv 2002; 57:205-10. [PMID: 12357521 DOI: 10.1002/ccd.10301] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
To clarify mechanisms of restenosis following percutaneous transluminal mitral commissurotomy (PTMC), we studied 253 patients (25% male) with PTMC using an Inoue balloon. Initial success (defined as either a mitral valve area >or= 1.5 cm(2) or more than twice the pre-PTMC valve area) was achieved in 95% of patients. During a mean follow-up period of 8 +/- 3 years, 12 patients underwent mitral valve replacement due to mitral valve restenosis. Visual inspection of the 12 resected valves with restenosis did not reveal fusion of the commissures. Histologically, all the resected mitral valves had evidence of end-stage rheumatic valvular disease, such as severe fibrosis and calcification. Deterioration of Wilkins echo score supported rheumatic disease progression in the leaflets and subvalvular region. Therefore, restenosis is not due to recurrence of fusion in commissures in these Japanese patients. Histologic and echocardiographic findings suggest that restenosis is based on end-stage valvular disease.
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Affiliation(s)
- Takahiro Tsuji
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
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