Usefulness of short-term symptomatic status as a predictor of mid- and long-term outcome after balloon mitral valvuloplasty

Impact of left atrial compliance improvement on functional status after percutaneous mitral valvuloplasty

BACKGROUND

Conventional hemodynamic parameters may not accurately predict symptomatic improvement after percutaneous mitral valvuloplasty (PMV). Changes in left heart chamber compliance following adequate relief o0066 mitral stenosis (MS) may be useful in determining functional capacity after PMV. This study aims to determine the acute effects of PMV on compliance of the left heart and whether its changes relate to the patient's functional capacity.

METHODS

One-hundred thirty-seven patients with severe MS undergoing PMV were enrolled. Left atrial (C_a ) and left ventricular (C_v ) compliance were invasively estimated and net atrioventricular compliance (C_av ) was calculated before and immediately after the procedure. B-type natriuretic peptide (BNP) levels were obtained before and 24 hr after the procedure. The primary endpoint was functional status at 6-month follow-up, and the secondary endpoint was a composite of death, mitral valve (MV) replacement, repeat PMV, new onset of atrial fibrillation, or stroke in patients in whom PMV was successful.

RESULTS

The mean age was 43 ± 12 years, and 119 patients were female (87%). After PMV, C_a and C_av improved significantly from 5.3 [IQR 3.2-8.2] mL/mmHg to 8.7 [5.3-19.2] mL/mmHg (P < 0.001) and 2.2 [1.6-3.4] to 2.8 [2.1-4.1] mL/mmHg (P < 0.001), respectively, whereas C_v did not change (4.6 [3.2-6.8] to 4.4 [3.1-5.6]; P = 0.637). Plasma BNP levels significantly decreased after PMV, with no correlation between its variation and changes in left chamber compliance. At 6-month follow-up, NYHA functional class remained unchanged in 32 patients (23%). By multivariable analyses, changes in C_a immediately after PMV (adjusted OR 1.42; 95% CI 95% 1.02 to 1.97; P = 0.037) and younger age (adjusted OR 0.95; CI 95% 0.92-0.98; P = 0.004), predicted improvement in functional capacity at 6-month follow-up, independent of postprocedural data. The secondary endpoint were predicted by post-PMV mean gradient (adjusted HR 1.363; 95% CI 95% 1.027-1.809; P = 0.032), and lack of functional improvement at 6-month follow-up (adjusted HR 4.959; 95% 1.708-14.403; P = 0.003).

CONCLUSIONS

C_a and C_av increase significantly after PMV with no change in C_v . The improvement of C_a is an important predictor of functional status at 6-month follow up, independently of other hemodynamic data. Postprocedural mean gradient and lack of short-term symptomatic improvement were predictors of adverse outcome.

Advances in percutaneous treatment for adult valvular heart disease

Valvular heart disease occurs in 2-3% of the general population with an increase in prevalence with advancing age. The aetiology of valvular heart disease has evolved in recent decades with degenerative aortic and mitral valve disease supplanting rheumatic heart disease as a primary cause. The common valve lesions to be discussed in this article are aortic stenosis and mitral regurgitation. The traditional approach to calcific aortic stenosis when either symptoms or left ventricular impairment develops is surgical aortic valve replacement and it remains a treatment with excellent outcomes. In recent years there has been interest in less invasive approaches, including percutaneous and transapical aortic valve implantation. With refinements in technology these approaches are becoming a potential treatment option, primarily for high-risk patients who may otherwise be unsuitable for traditional open surgical treatment. Catheter-based approaches for mitral valve disease are also evolving. Mitral regurgitation may often be the result of mitral annular dilatation seen in patients with an enlarged left ventricle or left atrium. Percutaneous implantation of a constricting device in the coronary sinus, which lies in close proximity to the mitral annulus, results in a change to the geometry of the mitral valve and reduced regurgitation. Another technique in patients with degenerative mitral regurgitation is the endovascular edge-to-edge repair in which coaptation of the mitral valve leaflets can be improved with a percutaneously deployed clip. Small patient series indicate that these new techniques are promising. As such, advances in percutaneous interventional and surgical approaches have the potential to further improve outcomes for selected patients with valvular heart disease.

Predicting success and long-term outcomes of percutaneous mitral valvuloplasty: a multifactorial score

BACKGROUND

Percutaneous mitral valvuloplasty (PMV) success depends on appropriate patient selection. A multifactorial score derived from clinical, anatomic/echocardiographic, and hemodynamic variables would predict procedural success and clinical outcome.

METHODS

Demographic data, echocardiographic parameters (including echocardiographic score), and procedure-related variables were recorded in 1085 consecutive PMVs. Long-term clinical follow-up (death, mitral valve replacement, redo PMV) was performed. Multivariate regression analysis of the first 800 procedures was performed to identify independent predictors of procedural success. Significant variables were formulated into a risk score and validated prospectively.

RESULTS

Six independent predictors of PMV success were identified: age less than 55 years, New York Heart Association classes I and II, pre-PMV mitral area of 1 cm(2) or greater, pre-PMV mitral regurgitation grade less than 2, echocardiographic score of 8 or greater, and male sex. A score was constructed from the arithmetic sum of variables present per patient. Procedural success rates increased incrementally with increasing score (0% for 0/6, 39.7% for 1/6, 54.4% for 2/6, 77.3% for 3/6, 85.7% for 4/6, 95% for 5/6, and 100% for 6/6; P < .001). In a validation cohort (n = 285 procedures), the multifactorial score remained a significant predictor of PMV success (P < .001). Comparison between the new score and the echocardiographic score confirmed that the new index was more sensitive and specific (P < .001). This new score also predicts long-term outcomes (P < .001).

CONCLUSION

Clinical, anatomic, and hemodynamic variables predict PMV success and clinical outcome and may be formulated in a scoring system that would help to identify the best candidates for PMV.

Impact of concomitant aortic regurgitation on percutaneous mitral valvuloplasty: Immediate results, short-term, and long-term outcome

BACKGROUND

The aim of the study is to examine the effect of concomitant aortic regurgitation (AR) on percutaneous mitral valvuloplasty (PMV) procedural success, short-term, and long-term clinical outcome. No large-scale study has explored the impact of coexistent AR on PMV procedural success and outcome.

METHODS

Demographic, echocardiographic, and procedure-related variables were recorded in 644 consecutive patients undergoing 676 PMV at a single center. Mortality, aortic valve surgery (replacement or repair) (AVR), mitral valve surgery (MVR), and redo PMV were recorded during follow-up.

RESULTS

Of the 676 procedures performed, 361 (53.4%) had no AR, 287 (42.5%) mild AR, and 28 (4.1%) moderate AR. There were no differences between groups in the preprocedure characteristics, procedural success, or in the incidence of inhospital adverse events. At a median follow-up of 4.11 years, there was no difference in the overall survival rate (P = .22), MVR rate (P = .69), or redo PMV incidence (P = .33). The rate of AVR was higher in the moderate AR group (0.9% vs 1.9% vs 13%, P = .003). Mean time to AVR was 4.5 years and did not differ significantly between patients with no AR, mild AR, or moderate AR (2.9 +/- 2.1 vs 5.7 +/- 3.6 vs 4.1 +/- 2.5 years, P = .46).

CONCLUSIONS

Concomitant AR at the time of PMV does not influence procedural success and is not associated with inferior outcome. A minority of patients with MS and moderate AR who undergo PMV will require subsequent AVR on long-term follow-up. Thus, patients with rheumatic MS and mild to moderate AR remain good candidates for PMV.

Predictors of Surgery After Percutaneous Mitral Valvuloplasty

BACKGROUND

Percutaneous mitral valvuloplasty (PMV) is a minimally invasive treatment option for selected patients with mitral stenosis (MS). In general, the procedure is well-tolerated with a high success rate. However, relatively little is known about the predictors of surgical intervention after PMV.

METHODS

A retrospective analysis was performed on 243 patients undergoing PMV at a single institution over a 14 year period.

RESULTS

Fifty (21%) of 243 patients, comprising 44 women and 6 men and aged 55 +/- 14 years, underwent cardiac surgery at a median interval of 6 months (range, 0 to 130) after PMV. Nine (18%) underwent a procedure within 15 days, and 41 (82%) had a procedure more than 15 days after the valvuloplasty. After PMV, surgery-free survival was 85% at 1 year, 83% at 2 years, 81% at 3 years, 80% at 4 years, and 80% at 5 years.

CONCLUSIONS

The need for surgery after PMV is not uncommon. Independent predictors of surgery after PMV included severity of mitral regurgitation (p < 0.003) and a higher echo score (p < 0.039).