Retrograde nontransseptal balloon mitral valvuloplasty: immediate results and intermediate long-term outcome in 441 cases--a multicenter experience

Emerging Transcatheter Therapies for Valvular Heart Disease: Focus on Mitral and Tricuspid Valve Procedures

The emergence of percutaneous treatment options provides novel therapeutic alternatives for older and feeble patients who are at high risk for any surgical procedure. The purpose of our review was to offer an up-to-date analysis of the rapidly expanding field of percutaneous technologies for mitral, tricuspid, and pulmonary procedures. Edge-to-edge repair is an established treatment for secondary mitral regurgitation (MR), while transcatheter mitral valve replacement is a potential and expanding option for managing both secondary and primary MR. However, additional advancements are necessary to enhance the safety and feasibility of this procedure. Transcatheter tricuspid intervention is an emerging option that was conceived after the success of transcatheter procedures in aortic and mitral valves, and it is currently still in the early stages of advancement. This can be attributed, at least in part, to the previously overlooked effect of tricuspid regurgitation on patient outcomes. The development of edge-to-edge repair represents the forefront of innovations in transcatheter procedures. There is a scarcity of data about tricuspid annuloplasty and replacement, and further study is necessary. Transcatheter mitral, tricuspid, and pulmonary procedures show prospects for the future, while their role in clinical practice has not been definitively established.

Non-surgical treatment of Lutembacher syndrome: combined percutaneous transcatheter therapy

A woman in her 30s presented with progressive worsening of dyspnoea for 6 months. On evaluation, she was diagnosed with severe rheumatic mitral stenosis (mitral valve area of 0.6 cm2) and a large ostium secundum atrial septal defect (21 mm) with a left to right shunt and severe pulmonary artery hypertension. She was diagnosed with Lutembacher syndrome and was evaluated for suitability of a percutaneous approach. She was subjected to a combined procedure of percutaneous transluminal mitral commissurotomy followed by device closure of the atrial septal defect. The patient tolerated the procedure, remained haemodynamically stable and was discharged after 4 days. This procedure can prevent the morbidity and mortality associated with anaesthesia and cardiac surgery and the psychological trauma of a thoracotomy scar particularly in a female patient, as well as obviate the need for prolonged hospital stay.

Difficulties to enter the left ventricle during percutaneous transvenous mitral commissurotomy (PTMC)- our experiences of 80 cases with modified techniques

Background

Percutaneous transvenous mitral commissurotomy (PTMC) is the standard of treatment for symptomatic severe rheumatic mitral stenosis (MS). PTMC has the standard Inoue technique, but we have to modify the procedure in many technically challenging cases, especially to cross the mitral valve.

Methodology

Two over-the-wire strategies to enter the LV were taken in 80 complex cases of PTMC. The first one was done by exchanging the J-shaped wire from the balloon, introducing the spring wire into it, and pushing it into LV. The second one-removal of balloon keeping the spring wire in LA and the Mullin's sheath was introduced, and the tip of the wire was pushed into LV, and the balloon was introduced over the wire. We also changed the left atrium (LA) graphy in the RAO view instead of the AP view to facilitating entry into LV.

Results

We succeeded in 76 (95 %) cases. Strategy one was applied to all but successful in only 25 cases (31 %), and strategy 2 was applied in the remaining. Strategy 1 required less procedural time and fluoroscopic time in comparison to strategy 2 (40 ± 10 vs 60 ± 16 min, 25 ± 7 vs 35 ± 8 min). After modification of taking the LA graphy in RAO view, our rate of facing the difficulties decreased from 21 % to 9 %. Critical MS (31 %) and the giant LA (30 %) were the topmost causes of difficulties. No major complications were recorded.

Conclusion

Over-the-wire entry into LV is cost-effective, requiring no new equipment and is safe and can be used in complex cases.

Combined Percutaneous Procedure in Patient with Lutembacher Syndrome: A Case Report and Real-World Experience Review

Even cardiac surgery has been accepted as the standard therapy for Lutembacher syndrome, a combination of congenital ostium secundum atrial septal defect (ASD) and acquired mitral valve stenosis (MVS), it also owns many limitations and disadvantages. Therefore, seeking for a less invasive therapy with the same efficacy may be worthwhile. Thanks to the development in technology and experience gaining in cardiovascular intervention, the combination of the two proved effective procedures, including percutaneous MVS treatment using balloon valvuloplasty and percutaneous ASD closure using atrial septal occluders, can be utilized as an attractive alternative therapy for these conditions. Here, we present a successful percutaneous intervention in Lutembacher syndrome using the combination of mitral balloon valvuloplasty and ASD device closure and thoroughly review the experience of using this combined procedure existing in the literature.

Predictors of Long-Term Outcomes of Percutaneous Mitral Valvuloplasty in Patients with Rheumatic Mitral Stenosis

PURPOSE

We determined factors associated with long-term outcomes of patients who underwent successful percutaneous mitral balloon valvuloplasty (PMV).

MATERIALS AND METHODS

Between August 1980 and May 2013, 1187 patients underwent PMV at Severance Hospital, Seoul, Korea. A total of 742 patients who underwent regular clinic visits for more than 10 years were retrospectively analyzed. The endpoints consisted of repeated PMV, mitral valve (MV) surgery, and cardiovascular-related death.

RESULTS

The optimal result, defined as a post-PMV mitral valve area (MVA) >1.5 cm² and mitral regurgitation ≤Grade II, was obtained in 631 (85%) patients. Over a mean follow up duration of 214±50 months, 54 (7.3%) patients underwent repeat PMV, 4 (0.5%) underwent trido-PMV, and 248 (33.4%) underwent MV surgery. A total of 33 patients (4.4%) had stroke, and 35 (4.7%) patients died from cardiovascular-related reasons. In a multivariate analysis, echocardiographic score [p=0.003, hazard ratio=1.56, 95% confidence interval (CI): 1.01-2.41] and post-MVA cut-off (p<0.001, relative risk=0.39, 95% CI: 0.37-0.69) were the only significant predictors of long-term clinical outcomes after adjusting for confounding variables. A post-MVA cut-off value of 1.76 cm² showed satisfactory predictive power for poor long-term clinical outcomes.

CONCLUSION

In this long-term follow up study (up to 20 years), an echocardiographic score >8 and post-MVA ≤1.76 cm² were independent predictors of poor long-term clinical outcomes after PMV, including MV reintervention, stroke, and cardiovascular-related death.

Management of atrial fibrillation in patients with rheumatic mitral stenosis

Atrial fibrillation (AF) is frequent in patients with rheumatic mitral stenosis (MS). Pressure overload leads to marked structural and electrical remodelling of left atrium. The frequency of persistent AF increases with age and paroxysmal, asymptomatic, AF seems even more frequent. The occurrence of AF worsens the haemodynamic tolerance of MS and markedly increases the risk of thromboembolic events. AF has a negative impact on the natural history of MS and on its outcome after commissurotomy. The respective indications of rhythm and rate control should be adapted to patient characteristics, particularly the consequences of MS, and take into account the high risk of recurrence of AF. Oral anticoagulant therapy is mandatory when AF complicates MS, regardless of its severity and CHA2DS2-VASc score. Non-vitamin K antagonists oral anticoagulants are not recommended in moderate-to-severe MS due to the lack of data. Percutaneous mitral commissurotomy does not appear to prevent the occurrence of AF in MS but should be considered as the first-line therapy when AF is associated with severe symptomatic MS, followed by the discussion of cardioversion or ablation. AF ablation should be considered in patients with mitral disease requiring intervention, but the ideal timing and techniques are difficult to determine due to the lack of appropriate specific randomised trials in patients with MS.

Is Transoesophageal Echocardiography Necessary for the Percutaneous Management of Lutembacher Syndrome: A Case Report

Lutembacher syndrome is defined as a combination of congenital Atrial Septal Defect (ASD) with an acquired Mitral Stenosis (MS). There are various challenges involved in the percutaneous management of Lutembacher syndrome. Here, we present a case that had a very small Left Atrium (LA) and Left Ventricle (LV) cavities with an anteriorly placed ASD. We used Transoesophageal echocardiography (TEE) to take a separate interatrial septal puncture and complete the Balloon Mitral Valvotomy (BMV) procedure. Finally both the defects in interatrial septum were closed with the help of a large device.

Retrograde non trans-septal balloon mitral valvotomy in mitral stenosis with interrupted inferior vena cava, left superior vena cava, and hugely dilated coronary sinus

A 22-year-old woman with severe mitral stenosis was referred to us for further evaluation and management. She was found to have severe mitral stenosis, severe tricuspid regurgitation with dilated right atrium and right ventricle with persistent left superior vena cava and hugely dilated coronary sinus. Valve was suitable for balloon mitral valvotomy. Cardiac catheterization showed interrupted inferior vena cava with azygos continuation to right atrium and large left superior vena cava draining to coronary sinus which was very much dilated. Right trans-jugular approach was tried for balloon mitral valvotomy, but was unsuccessful due to a very large right atrium and coronary sinus. Retrograde non trans-septal approach was used and balloon valvotomy was done successfully using a 24 mm × 40 mm TYSHAK balloon without any major complication. Reduction in the transmitral pressure gradient on cardiac catheterization data and transthoracic echocardiography confirmed successful procedure. Balloon mitral valvotomy can be done successfully in patients with the above unusual cardiac anatomy with no major procedural complications.

Percutaneous Mitral Valve Interventions

Percutaneous interventions for mitral valve disease represent both the oldest and the newest of catheter interventions. Balloon mitral valvuloplasty was among the first effective catheter therapies for valvular heart disease. The technique and device approach was initially reported by Inoue in 1982 and, remarkably, is virtually unchanged between then and now. Conversely, novel catheter therapies to repair mitral regurgitation are now in their infancy, with only the earliest human experience. This article details the spectrum of these therapies.

Late results of percutaneous mitral commissurotomy up to 20 years: development and validation of a risk score predicting late functional results from a series of 912 patients

BACKGROUND

Long-term follow-up after percutaneous mitral commissurotomy enables predictive factors of late results to be identified.

METHODS AND RESULTS

Late results of percutaneous mitral commissurotomy were assessed in 1024 consecutive patients. Good immediate results, defined as valve area ≥1.5 cm(2) without mitral regurgitation >2/4, were obtained in 912 patients (89%). These 912 patients were randomly split into 2 cohorts comprising 609 and 303 patients that were used to develop and validate, respectively, a scoring system predicting late functional results. The 20-year rate of good functional results (survival without cardiovascular death, mitral surgery, or repeat percutaneous mitral commissurotomy and in New York Heart Association class I or II) was 30.2 ± 2.0%. A multivariable Cox model identified 7 predictive factors of poor late functional results: higher final mean gradient (P<0.0001), interaction between age and final mitral valve area (P<0.0001) showing that the impact of valve area decreases with age, interaction between sex and valve calcification (P<0.0001) showing that the impact of valve anatomy is stronger in men, and interaction between rhythm and New York Heart Association class showing an impact of New York Heart Association class only in patients in atrial fibrillation (P<0.0001). A 13-point score enabled 3 risk groups to be defined, corresponding to predicted good functional results of 55.1%, 29.1%, and 10.5% at 20 years in the validation cohort.

CONCLUSIONS

Twenty years after percutaneous mitral commissurotomy in a population of patients with varied characteristics, 30% still had good functional results. Prediction of late functional results is multifactorial and strongly determined by age and the quality of immediate results. A simple validated scoring system is useful for estimating individual patient outcome.

Percutaneous Mitral Balloon Valvuloplasty for Patients with Rheumatic Mitral Stenosis

Percutaneous balloon dilatation of stenotic cardiac valves is used for the treatment of pulmonic, mitral, aortic, and tricuspid stenosis. Percutaneous mitral balloon valvuloplasty (PMV) has been used successfully as an alternative to open or closed surgical mitral commissurotomy in the treatment of symptomatic rheumatic mitral stenosis. PMV produces good immediate hemodynamic outcome, low complication rates, and clinical improvement in the majority of patients. PMV is safe and effective and provides clinical and hemodynamic improvement in rheumatic mitral stenosis. PMV is the preferred form of therapy for relief of mitral stenosis for a selected group of patients with symptomatic mitral stenosis.

The Impact of Age in the Immediate and Long-Term Outcomes of Percutaneous Mitral Balloon Valvuloplasty

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. (

Transjugular percutaneous inoue balloon mitral commissurotomy in a patient with inferior vena cava obstruction after liver transplantation

Percutaneous transvenous mitral commissurotomy was performed successfully via the transjugular approach in a patient with severe rheumatic mitral stenosis and obstruction of the inferior vena cava due to prior liver transplantation. This case demonstrates the advantage of the jugular approach in patients with difficult anatomy.

Feasibility of simplifying balloon mitral valvuloplasty by obviating left-sided cardiac catheterization using on-line guidance with transesophageal echocardiography

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.

[Mitral stenosis]

The decrease in the incidence of acute rheumatic fever in western countries has led to a sharp decrease in the incidence of mitral stenosis. This decrease also modifies the clinical presentation and mitral stenosis is now encountered in older patients who have severe impairment of valve anatomy. In developing countries, mitral stenosis remains a frequent disease. The management of patients with mitral stenosis has been modified by the development of percutaneous mitral commissurotomy whose safety and efficacy have been demonstrated in a number of studies with a follow-up of up to ten years. Percutaneous mitral commissurotomy is now the reference treatment for mitral stenosis with pliable valves in young patients and its efficacy has been validated in randomised trials versus surgery. Mitral stenosis in older patients, as it is encountered in western countries, is a more heterogeneous group. Predictive analysis has shown that the predictions of immediate and late results are multifactorial. This has led to consider the indications for percutaneous mitral commissurotomy in patients who do not have ideal anatomic conditions, when their other characteristics are favourable. This is particularly the case in young patients who do not have a very tight mitral stenosis (1-1.5 cm2) and who do not have an advanced heart disease. When the conditions are favourable, percutaneous mitral commissurotomy can be considered in patients who have few symptoms, in particular in order to reduce the thromboembolic risk.

The long-term outcome of balloon valvuloplasty for mitral stenosis

Percutaneous mitral commissurotomy (PMC) is the treatment of choice in young patients who have favorable valve anatomy. It affords an event-free survival greater than 90% at 5 to 7 years,. Economic considerations are the main limitation of PMC in such patients, who are mainly encountered in developing countries. Mitral stenosis in older patients with less favorable valve anatomy is the most frequent presentation in Western countries. This represents a heterogeneous group, but predictive analyses are helpful in deciding who should have PMC. The main conclusion is that the prediction of immediate and late results is multifactorial. Good results can be expected in young patients with unfavorable valve anatomy who do not have a very tight stenosis, are moderately symptomatic, and in sinus rhythm. In addition, PMC may reduce the thromboembolic risk related to mitral stenosis.

Predictors of long-term event-free survival and of freedom from restenosis after percutaneous balloon mitral commissurotomy

BACKGROUND

Most long-term studies after balloon mitral commissurotomy (BMC) were from industrialized countries. Less is known about the long-term results of BMC from developing countries where patients are younger with fewer mitral valve deformities.

METHODS

Between December 1987 and December 1998, we performed BMC in 654 patients whose mean age was 33 +/- 13 years. Baseline and postprocedural variables were evaluated to identify predictors of event-free survival (survival without repeat BMC or mitral valve replacement) and of freedom from restenosis defined as a mitral valve area (MVA) >/=1.5 cm(2) after BMC and <1.5 cm(2) at follow-up.

RESULTS

The actuarial survival rates were 98%, 98%, and 97% at 5, 7, and 10 years, respectively. The 5-, 7-, and 10-year event-free survival rates were 85%, 81%, and 72%. Multivariate predictors of a higher 10-year event-free survival rate were lower echocardiographic score (79% for a score </=8, 61% for a score of 9 to 11, 62% for a score >/=12, P <.001) and cardiac sinus rhythm (P =.04) before BMC, lower mean left atrial pressure (P <.001), lower mitral valve gradient (P <.001), and less than or equal to grade 2 mitral regurgitation (P =.036) after BMC. Restenosis occurred in 16% of patients. The restenosis-free rates were 88%, 80%, and 66% at 5, 7, and 10 years, respectively. A higher freedom from restenosis at 10 years was associated with a lower score (77% for a score </=8, 45% for a score of 9-11 and 50% for a score >/=12, P =.03) and a larger MVA before BMC (P =.03), a larger MVA (P <.001), and a lower mitral valve gradient (P =.04) after BMC.

CONCLUSIONS

BMC produces excellent 10-year results in patients with pliable mitral stenosis and good results in patients with semipliable or calcified mitral stenosis. BMC is the procedure of choice in patients with pliable valves and it is a reasonable treatment option in young patients with unfavorable mitral valve anatomy.

Retrograde nontransseptal balloon mitral valvuloplasty by the brachial artery approach

Retrograde nontransseptal balloon mitral valvuloplasty is a purely transarterial technique for percutaneous treatment of mitral stenosis. We report the first use of this technique via the brachial artery for a patient with aortoiliac atherosclerosis, and we comment on the difficulties and perspectives of this approach.

Rheumatic Mitral Stenosis

Patients with symptomatic mitral stenosis should undergo evaluation with transthoracic and transesophageal echocardiography (Table 1). Those patients with suitable valve morphology should be treated with percutaneous transvenous mitral commissurotomy (PTMC). Randomized trials of catheter commissurotomy have shown no differences in long-term outcome compared with surgical commissurotomy; there is therefore no role for surgical commissurotomy in patients who are suitable candidates for balloon commissurotomy. Mitral valve replacement should be recommended for those patients with valve deformity too severe to undergo catheter therapy. Some older patients who are less-than-ideal candidates for catheter therapy nonetheless may benefit from it as a palliative alternative to otherwise high-risk valve surgery. Asymptomatic patients should be screened for the presence of pulmonary artery hypertension. Those who have pulmonary artery systolic pressure at rest of greater than 50 mm Hg or who develop pulmonary artery systolic pressure of greater than 60 mm Hg with exercise should be considered for PTMC.